Failure to Provide Accessible Grievance Process
Penalty
Summary
The facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances, as evidenced by a lack of accessible grievance forms and insufficient communication about the grievance process. Record review showed that only a handful of written grievances were completed by residents or family members over a two-year period, with no grievances filed for most of 2024 and only a few in 2025. During a Resident Council meeting, multiple residents reported they were unaware of the grievance process, did not know how to file a grievance, and felt that reporting concerns to staff was ineffective. Observations throughout the facility revealed no visible information on how to file grievances, submit them anonymously, or access grievance forms. Interviews with staff indicated that grievance forms were not routinely provided to residents and were only available at nursing stations upon request. The Grievance Officer confirmed that forms were not accessible unless given by staff, and the Administrator acknowledged that residents had no means to submit grievances anonymously. This lack of an accessible and transparent grievance process placed residents at risk for unreported and unresolved grievances.