Failure to Maintain and Implement an Effective Grievance Process
Penalty
Summary
The facility failed to ensure a grievance process was available for residents as required by its own Grievance Process policy, which stated that the grievance program addresses concerns of residents, family members, and visitors and that the facility should make prompt efforts to resolve grievances. During the survey, when the SA requested copies of grievances covering the period from September 2025 through March 2026, the facility was only able to provide grievances from January 2026 through March 2026 and had no additional grievances available for the earlier months. In an interview, the Administrator, with the CRN present, confirmed there were no grievances available prior to January 2026 and the CRN acknowledged that the facility had identified its grievance process as needing a performance improvement plan. This lack of an available and functioning grievance process created the potential for psychosocial harm if residents’ concerns were not identified and addressed in a timely manner. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency centered on the facility-wide failure to maintain and implement an effective grievance process over the specified time period.
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