F0585

E

Failure to Address Repeated Grievances About Language Barriers and Ineffective Communication

Tampa, Florida Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide staff with adequate training and effective processes to address language barriers that had been repeatedly reported through grievances and resident council meetings. A cognitively intact resident with a Brief Interview for Mental Status (BIMS) score of 15 reported that language remained a significant barrier and that the resident council had been discussing this issue for months without resolution. This resident stated that staff would push their phones toward residents and attempt to use translator applications for communication, which the resident refused, believing they should be able to communicate with staff directly without a translator. The resident also reported hearing staff speak Spanish while caring for other residents who only spoke English.

Review of grievance records showed multiple complaints over several months related to staff not speaking or understanding English and staff speaking Spanish in front of non‑Spanish‑speaking residents, particularly on one unit. One grievance described a CNA who could not answer a resident’s question because she could not speak English and did not understand what the resident was asking, with no resolution documented. Another grievance from a resident and family member reported difficulty communicating with a specific care staff member due to a language barrier and poor response time; the only documented action was that the employee was counseled, with no follow‑up recorded. Resident council grievances repeatedly documented that CNAs on a particular station did not speak or knew very little English, that residents felt uncomfortable with staff using phones to translate, and that staff spoke Spanish to each other during mealtimes in front of English‑speaking residents. These items were repeatedly marked as “Not Resolved – Action Needed,” and residents noted that prior nursing grievances had not been resolved and that they wanted action taken.

Surveyor interviews further demonstrated ongoing communication problems and lack of effective staff training. An attempted interview with a CNA could not be completed because the CNA did not understand questions asked in English, evidencing a direct language barrier between staff and surveyors. A unit manager LPN stated that communication with staff on one unit was easier for her because she could use “Spanglish,” and acknowledged that CNAs on that unit had difficulty understanding clinical questions unless speech was slow and clear; she also confirmed that resident council repeatedly raised concerns about staff speaking Spanish in the hallways and that staff used translator applications on their phones to communicate with residents and English‑speaking staff. The Social Services Director acknowledged grievances related to language barriers and stated that staff had only been given verbal reminders not to speak other languages while caring for residents, which had not been effective. The Social Worker reported a potential issue with Spanish‑speaking staff and residents, stated that staff were not allowed to use translators to communicate with residents, and that being able to communicate and read English was a requirement for staff, but also stated that resolutions to grievances were not specifically documented. The Regional Director of Operations stated that the facility needed to go beyond verbal communication to resolve a repeating issue and that more should have been done to provide staff with resources and residents with communication in a language they understand, while facility policies required culturally competent care, effective communication in a language residents can understand, and sufficient guidance and training for staff on communication, which were not effectively implemented.