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F0585
E

Failure to Address and Document Resident Council Grievances

Orlando, Florida Survey Completed on 06-05-2025

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 act promptly and effectively upon grievances and recommendations raised by the resident council, as well as to demonstrate an active response for resolution of their complaints in a timely manner. Multiple residents reported that repeated complaints made during resident council meetings, particularly regarding cold temperatures and food/nutrition services, were not addressed or resolved by the facility. Review of resident council meeting minutes over a six-month period showed that issues such as cold temperatures and food concerns were brought up multiple times, but there was little to no documentation of follow-up actions or resolutions provided by the facility. Interviews with staff revealed that the Activities Director communicated resident council concerns to department managers but did not file formal grievances or consistently document actions taken. The Dietary Manager and Assistant Dietary Manager were not regularly present at resident council meetings and were unaware of ongoing food-related complaints. The Grievance Officer had not received any grievances from the resident council and assumed there were no complaints, indicating a lack of communication and formal grievance tracking between the resident council and facility administration. Facility policies required that grievances and concerns be documented, tracked, and followed up with written summaries of investigations and resolutions. However, the Activities Director acknowledged that repeated issues raised by residents were not formally documented or tracked, and there was no evidence that the facility's grievance policy was followed for concerns brought up by the resident council. This lack of documentation and follow-up resulted in unresolved resident concerns and a failure to honor residents' rights to voice grievances without discrimination or reprisal.

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