F0585

E

Failure to Implement Comprehensive Grievance Process and Notify Residents of Investigation Results

Clearwater, Florida Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a comprehensive grievance policy and to properly implement grievance procedures for multiple residents. The written Grievances – Resident Rights policy, last revised 07/2024, did not include required notification to the State Survey Agency and the State Long-Term Care Ombudsman program. Although the policy stated that the Grievance Officer would investigate grievances within five working days, coordinate with appropriate state and federal agencies as needed, and inform the resident or representative of the investigation findings and corrective actions, the facility did not follow these procedures as written. Surveyors found no documentation that residents or their representatives were informed of the results of grievance investigations for four sampled residents.

One cognitively intact resident with necrotizing fasciitis, Type 2 DM, chronic combined systolic and diastolic CHF, difficulty in walking, muscle weakness, and colostomy status filed two grievances received on the same date. One grievance concerned waiting too long for call light response related to a colostomy bag that had broken open with feces on the resident’s abdomen. During interview, the resident reported waiting three hours for the call light to be answered while worried about wound integrity and stated that no one came to talk to him after he filed the grievance. The Social Services Assistant (SSA) reported she gave the grievance to the ADON and that staff were trained on call lights, but she did not know how long the call light had gone unanswered and did not confirm whether a resident statement had been obtained. The DON, who was also the Abuse Coordinator, acknowledged that no resident interview or statement was attached to the grievance and stated she did not know how long the resident had waited, while also acknowledging that a three-hour wait would be a problem.

Another cognitively intact resident with chronic pain syndrome, heart failure, bipolar disorder, generalized muscle weakness, and neuromuscular bladder dysfunction filed a grievance about call light response time. The DON confirmed she completed this grievance after receiving it from staff, but there was no statement from the resident to show the concern had been directly discussed with the resident. A third cognitively intact resident with a displaced comminuted fracture of the left femur, lack of coordination, and need for assistance with personal care had a grievance filed by a family member, with the SSA listed as the investigator. A fourth cognitively intact resident with chronic pain syndrome, cervical disc degeneration, and generalized muscle weakness filed a grievance investigated by the ADON. For all four residents’ grievances, the section of the grievance forms designated for resident or responsible party notification of resolution, including name and signature, was left blank. Staff H stated that follow-up should have occurred with these residents, indicating that the facility did not document or demonstrate that residents were informed of the investigation findings or resolution of their grievances.

Overall, the survey findings showed that the facility’s written grievance policy lacked required elements for external notification, and the implemented grievance process did not include complete investigations or documented resident interviews for key complaints, particularly those involving call light response and customer service. The facility also failed to document that residents or their representatives were informed of the results of the grievance investigations and any actions taken, despite policy language requiring verbal and/or written notification with rationale. These omissions affected at least four cognitively intact residents who had filed grievances or had grievances filed on their behalf, and the staff directly involved in grievance handling were unable to provide basic investigative details such as the length of call light delays or evidence of resident interviews.