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F0565
E

Failure to Address and Resolve Resident Grievances from Resident Council Meetings

Everett, Washington Survey Completed on 07-21-2025

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 a system to ensure that grievances voiced by residents, particularly through Resident Council meetings, were properly documented, tracked, investigated, and resolved. Residents repeatedly reported issues such as loud TV noise, staff being boisterous at night, and cold food during meals. These concerns were consistently brought up in Resident Council meetings over several months, but there was no documentation of resolutions or evidence that grievance forms were completed or logged. The facility's grievance log did not reflect these ongoing concerns, and there was no follow-up or investigation into the issues raised. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Activity Director, who assisted with Resident Council meetings, did not consider concerns raised in these meetings as formal grievances and therefore did not complete grievance forms or track the issues. The Social Service Director, designated as the Grievance Officer, was not notified of any concerns from the Resident Council meetings and had not received any related grievance forms. The Administrator expected that grievances from Resident Council meetings would be documented and processed, but acknowledged that this was not occurring and that there was no established process for handling these concerns. Specific residents reported ongoing disturbances at night due to loud TVs and staff noise, which affected their ability to sleep. Observations confirmed that noise levels were high, including loud communication from staff devices. Despite these repeated complaints and direct observations, there was no evidence that the facility took appropriate steps to address or resolve the grievances, and staff members responsible for resolving such issues were unaware of the ongoing concerns.

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