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F0585
D

Failure to Promptly Resolve Resident Grievance Regarding CNA Care

Westminster, Colorado Survey Completed on 05-01-2025

Penalty

Fine: $32,860
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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 promptly resolve a grievance raised by a resident regarding the care provided by a certified nurse aide (CNA). The resident, who was cognitively intact and required significant assistance with activities of daily living due to multiple chronic conditions, reported that the CNA only changed her twice per eight-hour shift, did not communicate with her, and was perceived as rude. The resident expressed her concerns to multiple staff members, including leaving a message for the nursing home administrator (NHA), but did not receive feedback or resolution. A Concern and Comments form was completed by the resident, documenting her issues with the CNA and indicating that the concern was reported to an LPN. However, the form did not show any actions taken to address or resolve the grievance. Staff interviews confirmed that the resident had voiced her concerns as early as January, but no follow-up occurred until months later. The LPN acknowledged that the facility did not follow up with the resident about her concerns until the day of the survey interview, at which point the CNA was removed from the resident's care team. Additional staff interviews revealed that other nurses were aware of the resident's concerns for several months but were not aware of any actions taken or resolutions provided. The NHA stated he was not aware of the grievance until recently and had not received any messages from the resident. Despite the facility's grievance policy requiring prompt efforts to resolve complaints, the documentation and interviews demonstrated a lack of timely response and resolution for the resident's grievance.

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