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F0565
E

Failure to Address and Resolve Group Grievances Raised by Resident Council

Westminster, Colorado Survey Completed on 06-03-2025

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 group grievances brought up by the resident council, as required by its own grievance policy. The policy states that all grievances must be forwarded to the grievance official, with written acknowledgment provided within three calendar days, and a written resolution within 14 days, or interim updates if more time is needed. However, interviews with alert and oriented residents who regularly attended resident council meetings revealed that group grievances raised during these meetings were not consistently followed up on or resolved by the facility. While individual grievances were addressed, group concerns were not documented as resolved or brought back to the council for follow-up. Review of resident council meeting minutes from three consecutive months showed multiple group concerns, such as issues with building temperature, call light response times, staffing, meal options, and maintenance needs. There was no documentation in the minutes indicating that these group grievances were addressed or resolved. Staff interviews confirmed that while there was a process for individual grievances, there was no established process for following up on group grievances from resident council meetings. Only a few individual concerns resulted in work orders, with no evidence of resolution for the broader group grievances.

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