Failure to Address and Follow Up on Resident Grievances and Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident grievances and concerns in a timely manner, as evidenced by a review of facility documents, staff interviews, and policy review. Out of 75 grievances filed between April 2025 and September 2025, 30 had not been followed up on. Additionally, multiple concerns raised during Resident Council meetings from June through October 2025—including issues with untimely medication administration, undercooked food, staffing, staff approach, and showers—were not addressed or followed up on. The facility census at the time was 70 residents, indicating that the failure had the potential to affect all residents. Further review revealed inconsistencies in documentation and follow-up actions. For example, meeting minutes from August 2025 indicated that an LPN had been counseled for untimely medication administration, but the personnel file contained no documentation to support this. Interviews with the DON and Administrator confirmed that the grievances and concerns had not been addressed as required by facility policy, which designates the Administrator as the Grievance Official responsible for oversight and written decisions. The facility's policy also requires action and communication regarding Resident Council concerns, which was not followed.