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F0565
E

Failure to Address Group Grievances Raised by Resident Council

Colorado Springs, Colorado Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure prompt action was taken upon the filing of a group grievance, specifically regarding missing clothing, as brought up by the resident council. According to the facility's own policy, all grievances or recommendations from resident or family groups concerning resident care are to be considered and responded to in writing, including a rationale for the response. However, interviews with alert and oriented residents who regularly attended resident council meetings revealed that group grievances, such as the ongoing issue of laundry items being delivered to the wrong residents, were not followed up on or resolved. Residents reported that while individual grievances were sometimes addressed, group grievances raised in council meetings did not receive updates or resolutions in subsequent meetings, and the facility did not communicate how or when these issues would be resolved. Review of resident council meeting minutes over several months confirmed that concerns about missing or misdelivered laundry were repeatedly raised but not documented as addressed or resolved by the facility. Staff interviews further revealed that while there was a process for handling individual grievances, there was no established process for following up on group grievances from resident council meetings. Grievances discussed in meetings were not formally documented on facility grievance forms, and there was no system to ensure department managers provided updates or resolutions to the resident council, resulting in unresolved group concerns.

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