F0585

E

Failure to Document, Investigate, and Resolve Resident Grievances and Neglect Allegations

Jackson, Michigan Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly document, investigate, track, and resolve resident grievances, including allegations of neglect, as required by its grievance policy. The Nursing Home Administrator (NHA) reported that a resident had recently alleged receiving no care for 14 hours, but this allegation was not reported because it was determined it did not occur within a two-hour window. A concern form dated 2/16/26 documented that this resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed. The form indicated that management spoke with staff who claimed they had gotten the resident up multiple times and changed her when needed, and it was marked as investigation complete with staff education, but there was no evidence that the allegation of neglect was reported to the State and no supporting documentation in the medical record to show the neglect did not occur.

The report further describes multiple residents with care concerns that were not effectively captured or addressed through the grievance process. One resident with a history of stroke, moderate cognitive impairment, and dependence on staff for all ADLs had multiple undocumented care tasks, including hygiene, ADLs, toileting, and missed showers over nearly a month. This resident’s daughter reported that every time she visited, she found care problems such as soiled sheets and the resident leaning in bed almost falling out, and that she repeatedly voiced concerns to staff without any change and was not aware of a concern form process. Another resident, cognitively intact and requiring significant assistance for toileting and bathing, reported not receiving a shower for two weeks and only one shower in the past two months, despite having reported several complaints and having a concern form completed without follow-up or improvement. The NHA later verified there were no care concern forms for these residents in the past 30 days.

Additional deficiencies in grievance handling are linked to staffing-related neglect concerns for several other residents. A CNA reported that on a specific weekend night there were no CNA staff on one floor, only two nurses, and that three residents were left up in chairs all night, with one resident heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour night shift. The CNA stated a grievance form was completed and given to the NHA, and that potential allegations of neglect were reported to nursing staff. An LPN confirmed that no CNA worked that night, that three residents were left in chairs and remained in the same clothing when day shift arrived, and that management was informed because resident care needs were not met. Despite this, the NHA reported having no knowledge of the three residents who remained up all shift and no concern forms for the involved residents in the past 30 days. A former scheduler reported being unable to fill CNA staffing on multiple occasions, being instructed to add non-CNA staff to the schedule, and stated that concern forms related to unmet care needs and staffing were completed at least twice weekly and provided to the NHA and DON, but these were not reflected in the grievance tracking or resolution process.