F0585

D

Failure to Adequately Investigate and Resolve Resident Grievances About Incontinence Care

Laplata, Maryland Survey Completed on 01-09-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances related to incontinence care and other concerns. Record review showed that on 12/9/25 three concerns about Resident #10 were reported to social services: the resident’s incontinence briefs were leaking more than previous ones and their clothing smelled of urine more frequently, two medical shoe boots were missing, and construction odors were bothering the resident. The grievance form indicated that the Nursing Home Administrator (NHA) investigated the grievance and signed it as resolved on 12/10/25, but the written response did not address the concern about the leaking incontinence briefs.

A second grievance dated 12/24/25, completed by Unit Manager #4, documented that the same resident again reported leaking incontinence briefs that caused urine odor on their clothing and led them to miss a facility event. The resident stated that the previous briefs did not leak and that they had been complaining without anyone listening. The follow-up section stated that the current brief was not new and that a pad would be added under the brief, and it was marked as resolved. However, there was no documented investigation into why the briefs were leaking or what intervention would prevent recurrence. During an interview, the resident reported ongoing feelings that staff were not responsive to their grievances. In a separate interview, the NHA, who served as Grievance Officer, acknowledged that the incontinence brief concern was not addressed when first reported and that the second grievance was not investigated to ensure an effective resolution for the resident.