Failure to Process and Track Resident Grievance for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly process and resolve a resident grievance related to missing personal property, as required by its Resident Rights Grievances Policy and Procedure. The policy, revised in 3/2023, assigns the grievance officer responsibility for overseeing the grievance process, receiving and tracking grievances through conclusion, leading investigations, maintaining confidentiality, and issuing written grievance decisions. It also requires staff to immediately report any grievance alleging misappropriation of resident property to the grievance officer, with reports to be made available within seven business days and a summary report of the investigation available to the resident. Despite these requirements, the facility’s grievance list for 7/2025 and 8/2025 contained no grievances for the resident in question. The resident, admitted in 2/2025 with a diagnosis including depression and documented as cognitively intact with a BIMS score of 15 on an 8/31/25 MDS, reported missing jewelry, an oximeter, and art supplies in 8/2025. The resident stated these missing items were reported both to staff and during a resident council meeting, and the 8/26/25 Resident Council minutes reflected that residents reported missing items from their rooms, with this resident in attendance. A CNA reported that the resident told her in 8/2025 about missing earrings and an oximeter and that she reported this to the charge nurse, but did not assist with another grievance form because the resident had completed one the day before. The Director of Social Services and Recreation stated he did not remember any grievances for this resident regarding missing items and that no grievances were found for the resident for 8/2025, suggesting the grievance may have been submitted but lost due to confusion among multiple staff. The Administrator stated he would have expected staff to complete a grievance and have it resolved within five days, which did not occur in this case.
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