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F0585
F

Failure to Address and Resolve Resident Grievances Regarding Staff Attitudes

West Frankfort, Illinois Survey Completed on 09-16-2025

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 address and resolve concerns raised by residents regarding the rude and disrespectful attitudes of some Certified Nurse Assistants (CNAs), as documented in resident council meeting minutes. Despite the issue being discussed and recorded in the resident council, there was no evidence that a grievance or concern form was completed, nor was there any documentation of investigation or resolution. Multiple residents, all cognitively intact as indicated by their BIMS scores, reported ongoing issues with staff rudeness, including dismissive or aggressive responses when requesting assistance. Staff interviews confirmed awareness of the problem, with some CNAs and the Activities Director acknowledging that certain staff members had been rude to residents. However, key personnel such as the Social Service Director, Administrator, and Director of Nursing were unaware of the complaints, and no in-service training or corrective action was documented. The facility's grievance policy requires prompt documentation, investigation, and resolution of all grievances, including those discussed in resident council meetings. However, the policy was not followed in this instance, as the concern about staff attitudes was neither formally documented nor addressed. The lack of communication and follow-through among staff and administration resulted in the residents' grievances remaining unresolved, affecting all 52 residents in the facility.

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