Failure to Document and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were properly documented and resolved over a five-month period. Review of Resident Council meeting minutes from June through October 2025 showed repeated discussions and requests from residents for more frequent provision of ice water and snacks. Despite these ongoing concerns, there was no documentation in the facility's grievance log reflecting these group issues, nor evidence that the concerns were formally tracked or followed up on as grievances. Interviews with two cognitively intact residents confirmed that the issues of hydration and snacks were discussed multiple times in Resident Council meetings, but no changes were observed in response to their requests. One resident reported that water refills were inconsistently provided, and another stated she had to get up at night to find water due to lack of refills. The Activities Director acknowledged that group concerns from Resident Council meetings were not entered as grievances, but rather discussed informally in Interdisciplinary Team (IDT) meetings without formal tracking or follow-up. She confirmed that if such concerns were entered as grievances, they would be tracked. The Nursing Home Administrator stated that grievances could be submitted by anyone and were logged and tracked by social services, but was unaware that Resident Council concerns were not being entered as grievances. Review of the facility's grievance policy indicated that all complaints or grievances should be documented, acted upon, and tracked, with prompt efforts made to resolve them. However, the facility did not follow its own policy regarding group concerns raised by the Resident Council, resulting in a lack of documentation and resolution for these grievances.