Failure to Timely Resolve Resident Grievances Regarding Showers
Penalty
Summary
The facility failed to respond to and resolve a resident's grievances in a timely manner, specifically regarding concerns about receiving scheduled showers. A resident with a history of hemiplegia, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension reported not having received a shower in over a month, despite multiple complaints made by both the resident and their family to staff and administration. Grievance records showed that concerns about missed showers were documented on several occasions, but the grievance dated 11/11/2025 lacked documentation of resolution, the complainant's response, or the administrator's signature. Interviews with staff confirmed that the grievance process was not completed as required, and there was no evidence of follow-up, investigation, or communication of resolution to the resident or family. Review of the resident's shower sheets confirmed that no showers were documented for a 13-day period, and the resident did not receive showers as scheduled until after the survey began. Facility policy requires grievances to be resolved within 72 hours and mandates documentation of all showers provided or declined. However, the process was not followed, as grievances were not properly reviewed, signed off by the administrator, or communicated back to the complainant, resulting in unresolved concerns and a lack of timely care for the resident.