Failure to Notify Resident Council of Grievance Resolutions
Penalty
Summary
The facility failed to consider and act promptly upon the grievances and recommendations of the Resident Council regarding issues of resident care and life in the facility. Specifically, for multiple grievances raised by the Resident Council in February, March, and August 2025, there was no evidence that the facility provided a verbal or written response to the Council addressing the reported concerns. The grievances included issues with nursing services, dietary services, and housekeeping services. Documentation in the grievance logs often indicated that residents were notified of resolutions through one-to-one discussions, but there was no documentation that the Resident Council as a group was informed of the outcomes, particularly for grievances submitted collectively by the Council. Interviews with residents revealed that none of the nine Resident Council members interviewed had received feedback regarding their grievances from August, and they stated that issues they had reported remained unresolved. Residents also reported that staff rarely attended Council meetings to discuss grievance resolutions, with only occasional attendance by the administrator and dietary manager. The Assistant Director (AD) confirmed that while she took notes and submitted grievances on behalf of the Council, there was no consistent follow-up or communication of resolutions to the Council members. The Social Worker (SW), responsible for handling grievances, stated that she would typically notify the Council president individually but had no documentation of such communication, and acknowledged that resolutions were not routinely shared with the Council as a group. The facility's grievance policy required that grievances be taken seriously, documented, investigated, and that findings and resolutions be communicated to the complainant in a timely manner. However, the policy was not followed in practice, as evidenced by the lack of documentation and communication with the Resident Council regarding the outcomes of their grievances. The administrator and other department heads believed that residents had been informed of resolutions, but resident interviews and record reviews did not support this. The failure to notify the Resident Council of grievance outcomes was attributed to workload issues and lack of a clear process for group communication.