Failure to Complete Unusual Occurrence Report After Resident-to-Resident Altercation
Summary
The deficiency involves the facility’s failure to follow its own Unusual Occurrence Report (UOR) policy after a resident-to-resident incident involving two residents with Alzheimer’s disease. An anonymous complaint to the State Agency alleged that one resident (R82) grabbed another resident’s (R90’s) head aggressively, that staff intervened, and that the Nursing Home Administrator later stated he had watched video and characterized the action as “petting” rather than an aggressive act. The complaint further alleged that this resident-to-resident incident was not reported by the facility as required. Record review showed that R82 had a diagnosis of Alzheimer’s disease and a Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 99/15, indicating severe cognitive impairment. R90 also had Alzheimer’s disease and an MDS BIMS score of 00/15, indicating cognitive impairment. Behavior charting in R82’s electronic medical record documented that on 12/06/2025 at 5:00 p.m., R82 exhibited aggression toward others, with additional information stating that the resident, while getting ready to eat dinner and standing next to R90, put his hands over her hair/eyes. This behavior entry was documented by LPN S. In an interview, the Nursing Home Administrator reported awareness of a situation between R82 and R90 about a month prior but stated he did not have a completed UOR for the event. In a separate interview, LPN S reported that on the date of the incident, R82 grabbed onto R90’s head and the two residents were immediately separated. LPN S stated that a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors, especially toward staff, but she was unsure whether the DON or any other staff member completed a UOR and confirmed that she did not complete one herself. Review of the facility’s UOR policy showed that resident-to-resident altercations are defined as unusual occurrences requiring completion and investigation of an Unusual Occurrence Report, including assessment, documentation, and follow-up, which was not done for this incident.
Penalty
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Grievance forms and procedures were not posted in prominent locations, and three residents in council said they did not know how to file a grievance. An AD said residents could ask social services for help, but she did not have the form and was unsure which form to use after new ownership. An LSW said concerns were usually handled in progress notes, and the administrator confirmed residents could not file grievances anonymously, despite the facility policy stating grievance information, anonymous filing rights, and grievance official contact info would be posted.
A resident with multiple orthopedic and neurologic diagnoses and a BIMS of 13 voiced frustration that therapy was not scheduled at specific times and said it caused him to wait around all day and risk missing appointments. Staff acknowledged that residents commonly complained about therapy timing, but the concern was not documented as a grievance, investigated, tracked, or followed up through the facility's grievance process, despite the policy requiring verbal complaints to be recorded and resolved.
The facility failed to maintain an effective grievance process for residents and family members to file grievances verbally or anonymously. Although the Resident Rights and grievance policy allowed oral and anonymous complaints, only small grievance notices were posted, and no grievance forms or grievance box were available at the receptionist area. Residents said they did not know how to file anonymously, the receptionist was unsure how anonymous filing worked, and the DON stated the facility previously had grievance forms and a drop box but they were removed.
Failure to Resolve Family Grievances: A resident with severe dementia and a BIMS of 0 had repeated unexplained skin tears and an incident where a male resident was found in her bed in the secured unit. A family member reported concerns about staffing, supervision, and the resident’s injuries, but said ADM, DON, HR, and ADON did not answer her questions or listen to her. Grievance records did not show the family’s concerns were tracked as grievances, and the ADM and DON discussed the issues with the RP instead of the person who raised them.
Grievance handling failures for resident complaints: A resident reported missing money to a CNA, but no grievance was filed. Another resident’s representative complained that an LPN missed an ordered nebulizer treatment and was rude and verbally abusive; the complaint was documented as resolved, but no written grievance decision was provided and the LPN continued working for several more days. A third resident called the DON after being left soiled in feces for about 2 hours, but the complaint was not initially entered in the grievance log and was only added later.
Grievance Process Not Followed: A resident with DM, hemiplegia, and schizoaffective disorder had multiple grievances filed by family regarding medication administration, physician service, and care. The facility did not provide written results or actions taken, grievance reports were left incomplete and unsigned, and the family was not informed of the findings or resolutions.
Grievance Forms and Anonymous Filing Information Not Posted
Penalty
Summary
The facility failed to ensure grievance forms and grievance procedures were posted in prominent locations throughout the facility for residents and resident representatives to use, including the option to file anonymously. During a resident council meeting, three residents stated they were not aware of how to file a grievance. A walk-through of each unit found no grievance forms or procedures posted for residents or resident representatives to refer to. During interviews, the activity director stated residents had been told they could ask social services to help complete a grievance form, but she did not have a copy of the form and was not aware of which form to use since the facility had new owners. The licensed social worker stated her usual process was to address concerns right away and document the results in progress notes, and said residents could file a grievance with her or with the ombudsman. She also stated residents could obtain a form from her if they wanted to keep it anonymous, but the administrator later confirmed residents were not able to file a grievance anonymously. Review of the grievance log showed the last grievance form was completed in December 2025, and the facility policy stated grievance information would be posted in the facility and include the right to file grievances anonymously and the grievance official’s contact information.
Failure to Document and Resolve Resident Grievance About Therapy Scheduling
Penalty
Summary
The facility did not make prompt efforts to document, investigate, or resolve a resident grievance involving therapy scheduling. The resident involved, R121, was admitted with diagnoses including polyneuropathy, cervical disc disorder with myelopathy, spinal stenosis of the lumbar and cervical regions with neurogenic claudication, and osteoarthritis of both knees. His most recent MDS showed a BIMS score of 13 out of 15, indicating he was cognitively intact. His care plan identified that he was admitted following a hospital stay with a goal of returning home after short-term rehabilitation. During interview, R121 expressed frustration that therapy appointments were not scheduled at specific times and said this created chaos because he had to wait around all day and could miss therapy while trying to complete other activities. Surveyor review of the grievance log from 4/1/26 to 6/29/26 showed no grievances related to therapy scheduling. Staff interviews showed that residents commonly voiced concerns about not having set therapy times, but these concerns were handled informally rather than documented as grievances. The Rehab Director stated residents often complained about the lack of a set schedule, and the Physical Therapist said complaints were sometimes passed to the Rehab Director or written as preferences in notes, but she was unsure whether they were documented as grievances. The Director of Nursing stated she was not aware of residents' concerns about therapy scheduling, while the Social Worker acknowledged that residents had voiced concerns about wanting therapy at certain times and asked whether these concerns should have been logged as grievances. The Nursing Home Administrator stated he had heard something from the Rehab Director about therapy scheduling but believed it had been taken care of and did not look into it. The facility's grievance policy required verbal complaints to be recorded on a grievance form, forwarded to the Grievance Official, investigated, tracked to conclusion, and followed by a written decision, but those steps were not completed for R121's concern.
Ineffective Grievance Process and No Anonymous Filing Option
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members to file grievances verbally or anonymously. The facility's Resident Rights stated residents have the right to voice grievances without discrimination or reprisal, and the Grievance - Informal and Formal policy stated grievances may be filed in writing or orally and may be filed anonymously. However, during observation from 6/29/26 through 7/2/26, the facility only had three grievance signs posted, each printed on an 8 1/2 by 11-inch sheet with small font and listing staff contacts, phone numbers, and email addresses. There were no grievance forms or grievance box located at the receptionist area for residents, families, or visitors to file grievances anonymously. During the resident group interview, three alert residents stated they did not know who the grievance officer was or how to file a complaint anonymously. They said they would tell their aide or nurse about a concern with direct care, but preferred to file concerns anonymously because they did not want staff to be mad or upset with them. The receptionist stated he/she was not sure how a resident would file a grievance anonymously and said residents could call the front desk, which would notify the appropriate department while keeping the resident's identity private. The DON stated residents knew they could bring concerns to her or the charge nurses and said the facility previously provided grievance forms and a grievance drop box, but she was not sure why the new company removed them. The Administrator stated the facility posted signs explaining how to file grievances and said residents could file anonymously by using the grievance box located at the receptionist's desk, although the observation showed no grievance box there.
Failure to Resolve Family Grievances
Penalty
Summary
The facility failed to ensure a resident’s right to voice grievances was honored and failed to make prompt efforts to resolve grievances for a resident with severe cognitive impairment. Resident #3 had diagnoses including Alzheimer’s disease and severe dementia, and her quarterly MDS showed a BIMS score of 0, reflecting severe cognitive impairment. Her care plan identified her as needing placement in the cognitive impairment unit due to poor safety awareness and high elopement risk, with an intervention to maintain a routine for bathing, dressing, and eating. The resident experienced multiple skin tears and other injuries during her stay, and the incident log documented several events involving unexplained skin tears to her legs, arms, foot, and shin. The record also documented an incident in which a male resident was found lying in Resident #3’s bed in her room in the secured unit. A family member stated she observed on camera that the male resident entered the room, lay in bed with Resident #3 for about 30 minutes, and lightly tapped her arm, chest area over her gown, and hair. The family member also reported concerns about lack of supervision, lack of night checks, staffing concerns, and staff experience in the secured unit. A letter from the family member, submitted to the corporate office, listed concerns about repeated skin tears, inadequate staffing, lack of rounding, and the male resident entering Resident #3’s room and lying in her bed on more than one occasion. The facility grievance records from October 2025 through June 2026 did not show grievances related to that letter. The family member stated she tried to raise her concerns with administrative staff, including the ADM, DON, HR, and ADON, but said she was not listened to and did not receive answers. The DON and ADM stated they discussed the concerns with the resident’s responsible party rather than with the family member who submitted the concerns, even though they acknowledged that their usual process was to address the grievance with the person who reported it.
Grievance handling failures for resident complaints
Penalty
Summary
The facility failed to ensure residents could voice grievances without discrimination or reprisal and failed to follow its grievance policy for multiple resident complaints. For Resident #11, who had diagnoses including polyosteoarthritis, chronic pain, difficulty walking, and moderate cognitive impairment, the record showed no grievance was entered for her report that someone stole $31 from her wallet. Resident #11 stated she told CNA G about the missing money, but CNA G said she did not report the complaint because she believed the nurses already knew about it. For Resident #30, who was admitted with emphysema, cerebral infarction, and cardiomyopathy and had intact cognition, the resident’s representative filed a grievance about LVN D not administering the morning nebulizer treatment as ordered and being rude and verbally abusive. The grievance record documented that LVN D was late giving the nebulizer treatment and was coached on medication administration and customer service, and the DON documented that the grievance was resolved in a one-to-one discussion. However, the resident’s representative also sent an email requesting a formal investigation and a written report, and during interview both the resident and representative stated they still had not received a written report of the investigative findings. The report also stated LVN D was allowed to work in the facility for 3 more days after the complaint was made. For Resident #12, who had diagnoses including neuromuscular dysfunction of the bladder, a history of falling, depressive disorders, bowel and bladder incontinence, and moderate cognitive impairment, the resident stated he was left in feces for about 2 hours after dinner and used the Administrator’s cell phone number to call her. The Administrator acknowledged receiving the call and said a CNA then went to the room. The grievance log initially had no entry for this complaint, and the Administrator later corrected the log and added a grievance entry dated for the incident. The Administrator documented that the resident was waiting for someone to change him and that she made sure someone went to take care of his needs.
Grievance Process Not Followed
Penalty
Summary
The facility failed to follow its grievance process for one resident by not providing written notification of grievance investigation results and actions taken, not ensuring grievance reports were signed, and not making the reports available to the resident or the resident’s representative. The resident had diagnoses including DM, hemiplegia, and schizoaffective disorder. The H&P dated 9/2/2025 indicated the resident had the capacity to understand or make decisions, and the MDS dated 5/20/2026 indicated cognition was moderately impaired and the resident required partial/moderate assistance with ADLs. During interview, the resident’s family member stated multiple grievances had been filed with facility administration regarding medication administration, physician service, and patient care, but the family was not informed of the findings of the investigations or any actions that would be taken to correct identified problems. Review of three Grievance/Complaint Reports for the resident showed blank fields for documentation of follow-up, resolution, and notification details, and the Grievance QA&A logs for April, May, and June 2026 had blank administrator signature fields and no yes/no response indicating whether grievances were resolved. The Administrator acknowledged the documents were incomplete and that families were not notified of actions taken and resolutions.
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