Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced by residents, both individually and during resident council meetings, were promptly identified, documented, investigated, and resolved according to facility policy. Specifically, concerns raised during a resident council meeting regarding delayed call light responses, a needed door repair, and complications with behavioral health counseling services were not entered into the grievance log, nor was there evidence of follow-up or communication of resolution to the residents. The facility's grievance policy required that all grievances be documented, investigated, and that residents be updated on the progress and outcome, but this process was not followed for the concerns raised in July 2025. Two residents with diagnoses including anxiety, depression, and other complex mental health disorders, both cognitively intact and able to express their needs, reported not receiving scheduled behavioral health counseling services. Interviews confirmed that these concerns were known to staff, including the Social Service Director, who acknowledged that the grievances were not logged or processed according to policy. The Grievance Officer also stated they were not informed of the grievances from the resident council meeting, resulting in a lack of appropriate documentation and follow-up.