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F0585
E

Failure to Log and Resolve Resident Grievances Raised in Resident Council Meetings

Shelton, Washington Survey Completed on 06-09-2025

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 implement and maintain a system to ensure that grievances verbalized by residents during Resident Council (RC) meetings were properly initiated, logged, addressed, and resolved in a timely manner. Over a period of four out of six months, residents repeatedly raised concerns during RC meetings regarding issues such as the lack of beverages with meals, delayed response to call lights, loud televisions, and privacy curtains not being closed. Despite these recurring complaints, the facility did not document the specific residents involved, the number of residents affected, or the details necessary to investigate and resolve the issues. Additionally, these concerns were not entered into the facility's grievance log as required by policy. Review of facility policies revealed that staff were responsible for reporting RC meeting concerns to the Administrator or department heads, and for providing written responses to grievances in accordance with the grievance policy. The policy also required that all grievances be logged, investigated, and followed up with the resident or their representative within five days. However, interviews and record reviews confirmed that these procedures were not followed, as no grievances related to the RC meeting concerns were logged or investigated, and residents were not informed of findings or actions taken. During interviews, residents confirmed that staff did not act promptly on grievances brought forward in RC meetings and did not follow up with them individually or as a group regarding corrective actions or the effectiveness of any interventions. Some residents indicated that unresolved issues, such as the lack of beverages with meals and slow call light response times, persisted over several months, leading them to stop raising the issues. The Director of Nursing acknowledged that grievances should have been generated and logged for these concerns, but this did not occur.

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