Failure to Implement Effective Grievance Process for Missing Personal Property
Summary
The deficiency involves the facility’s failure to implement an effective grievance process to ensure resident concerns, specifically about missing personal property, were documented, investigated, and resolved in a timely manner. The facility’s own grievance logs from January to March 2026 showed no grievances related to missing personal property for three sampled residents, despite multiple reports of lost items. The facility’s policy stated that a Social Services designee serves as the Grievance Official, responsible for receiving, tracking, investigating, and resolving grievances, and that staff who receive a grievance must document it and forward it for follow-up. However, staff interviews and record reviews confirmed that these steps were not carried out for the missing property concerns. One resident with Alzheimer’s disease, dementia, major depressive disorder, and impaired cognition, who required assistance with ADLs and was occasionally incontinent, had all personal property reported missing by a family member. The missing items included labeled clothing, a hamper, slippers, blankets, robes, tank tops, and underwear. The family member stated the facility laundered the items and did not return them, that the resident was wearing clothing that did not belong to her, and that the family had to purchase replacement items. The family member reported the issue to multiple staff, including the charge nurse and the Administrator, and stated the Administrator was condescending and lacked empathy. The family member reported that the missing items, valued at approximately $350.45, had not been reimbursed, and the issue remained unresolved. Another resident with orthopedic aftercare following amputation, type 2 DM with hyperglycemia, and hypertensive heart disease, who had moderately impaired cognition and required maximal assistance for bathing and personal hygiene, reported that her purse and wallet had been missing for about three weeks. The missing items contained two checks. She stated she reported the loss to the facility, staff searched but did not locate the items, and she had not been reimbursed. She also stated she did not feel her property was safe and that social services did not assist her with the loss or with canceling the checks. A third resident with DM, bipolar disorder, and schizophrenia, who had intact cognition but was dependent or required maximal assistance for ADLs, reported that personal items such as hair clippers, styluses, and tweezers had been misplaced on multiple occasions over about five months, often after hospital transfers when belongings were packed. He stated he reported the missing items to staff, was told the issue would be reported to a supervisor, but received no follow-up and multiple items remained missing. The Social Services Assistant stated that when items were reported missing, staff should search laundry and rooms, check inventory sheets, and reimburse residents if listed items could not be located, and that missing items should be documented in progress notes and reported to Administration. The SSA acknowledged discussing missing clothing with the family member of the first resident and being aware of missing money and items for the third resident, but did not indicate that grievances had been initiated and stated she was unaware of a missing purse or checks for the second resident. She further acknowledged that grievances should be initiated when residents or families report concerns, including missing property, and that if missing items had been reported, they should have been documented and a grievance filed. The SSA admitted she did not usually handle grievances, was unsure of the grievance process, and that grievances for these missing property concerns had not been documented, resulting in a lack of follow-up and unresolved concerns. The DON stated that when a complaint cannot be resolved immediately, the grievance process should be followed and that missing personal property should have been handled as a grievance because it required investigation and follow-up. The DON acknowledged that no grievances were filed for the missing property complaints from the three residents and that the lack of a grievance process meant the issues were ignored and unresolved. The Administrator stated that when property is lost, Social Services should follow up and, if needed, replace or reimburse the resident, and that the grievance process should be used to ensure timely and efficient handling. The facility’s written grievance policy specified that residents and family members may voice grievances verbally or in writing regarding care, treatment, or other concerns, that staff receiving a grievance must document it and take immediate action as needed, and that the Grievance Official must investigate, follow up, keep the resident informed of progress, and provide a written decision with findings and corrective actions. Despite these requirements, the missing property concerns for the three residents were not entered into the grievance system, not documented as grievances, and not resolved through the required process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Grievance Procedure Information Not Posted or Discussed: The facility failed to make grievance/complaint filing information available to 10 of 10 residents reviewed. Residents stated they did not know they could file anonymously, did not know where to get or submit a grievance form, and were unaware of their right to a written decision. Observation showed prominent postings lacked grievance instructions, and the ADM stated he was the grievance officer and that the grievance process should have been discussed in Resident Council.
A resident grievance about a missing hearing aid was not fully investigated, documented, resolved, or communicated to the resident’s family member. The facility only documented an initial search of the room, bedding, and laundry, with no further follow-up in the resident’s chart. The SSD said the grievance had been assigned to someone else and no outcome was shared, while the family member reported receiving no updates. The DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days.
Failure to initiate a grievance after a resident reported that staff turned off the call light without providing assistance. The resident, who had pneumonia, CKD, and DM, said they needed help to use the restroom, but a staff member turned off the call light and did not return for 15 to 20 minutes. The concern was reported to an LPN, and the Administrator stated no grievance or investigation was initiated.
Failure to Process Resident Grievances: A resident’s RP and the Ombudsman raised concerns about repeated denial of access to the resident’s medical records, but the facility did not generate grievance reports and treated the issue as a records request matter rather than a grievance. The RP also alleged the resident was injured by staff during incontinent care, and the DON stated no grievance or self-report was made. The resident had severe cognitive impairment, was not interviewable, and had diagnoses including DM2, anxiety, adult failure to thrive, and vascular dementia.
Failure to Investigate and Document Resident Grievance: A resident with Parkinson's disease and other diagnoses reported that his roommate's loud TV and use of the heater were preventing sleep and making the room too hot to breathe. The resident said he had told the SW multiple times, but the concern was not resolved, was not included in the grievance file, and the LSW acknowledged she did not complete a grievance form or make follow-up.
The facility failed to fully document and log a resident grievance. A resident reported an incident involving a housekeeping employee making a comment in front of the resident’s visitor, but the staff section of the encounter form was left blank and the grievance was not entered on the encounter log. The CNO confirmed the incomplete documentation and missing log entry.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 10 of 10 confidential residents reviewed for grievances. During interviews, all 10 residents stated they did not know they could file a grievance anonymously, did not recall the grievance procedure being discussed in Resident Council, and had not observed a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to give it to, what happened after a grievance was filed, or that they had the right to receive a written decision once their grievance was resolved. Observation of prominent postings on 06/16/2026 at 4:25 PM showed the facility did not include instructions regarding the grievance procedure with the postings. During interview on 06/17/2026 at 10:15 AM, the ADM stated he was the grievance officer, that grievance forms were available on a shelf by the downstairs elevator and could also be obtained from any staff member, and that grievances were assigned to the appropriate department for resolution and documented on the grievance form. The ADM stated completed grievance forms were kept in a notebook for 3 plus years, that grievances were monitored in daily IDT meetings, and that he was not aware the grievance procedure was not being discussed in Resident Council. The grievance policy reviewed, last updated in January 2024, stated grievance forms would be kept in the foyer on each floor, any staff member could assist with completing the form, and completed forms would be given to social services.
Failure to Investigate and Communicate a Grievance About a Missing Hearing Aid
Penalty
Summary
The facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for one resident. The resident’s Customer Concern/Grievance, filed by a family member, reported that the hearing aid was missing. The facility documented an initial search of the room, bedding, and laundry, but no further investigation, follow-up, or resolution was documented. The resident’s progress notes from the date of the grievance through several weeks later contained no documentation about the missing hearing aid or grievance follow-up. During interviews, the SSD acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated, the family member reported receiving no updates or information after filing the concern, and the DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days with the complainant updated on progress and outcome.
Failure to Initiate Grievance for Resident Concern About Call Light Response
Penalty
Summary
The facility failed to initiate a grievance after Resident 138 raised a concern about staff customer service. Resident 138 was admitted with pneumonia, chronic kidney disease, and diabetes, and was able to make needs known. During observation and interview, Resident 138 was sitting in a wheelchair just inside the room door with an upset expression and stated they had turned on the call light because they needed help to use the restroom. Resident 138 stated a staff member entered the room, turned off the call light, and said they would return to assist, but the resident waited 15 to 20 minutes for the staff member to come back and was upset about having to wait. The concern was reported to an LPN, and during interview the Administrator stated that if a resident reported staff had turned off the call light without providing care, a grievance should be completed. The Administrator also stated that turning off the call light without providing care increased the likelihood of neglect if the staff member forgot to return. The Administrator stated no grievance or investigation was initiated in response to Resident 138's concern, and this did not meet expectations.
Failure to Process Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident’s representative could voice grievances without discrimination or reprisal and failed to establish grievance reports for concerns raised by the resident’s representative and the Ombudsman. Resident #30 was an elderly female with diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia, and her quarterly MDS reflected a BIMS score of 04 indicating severe cognitive impairment. She was not interviewable during observation because she responded inappropriately to questions. The resident’s representative stated she had requested access to the resident’s medical records for two years and had been denied both times. She reported bringing her concerns to Medical Records, Social Worker, DON, and Administrator, but said there was no resolution and only delays. The Ombudsman also reported concerns about the representative’s denial of access to the medical records and stated the situation was ongoing and unusual. The Social Worker stated the representative wanted the records, was directed back to Medical Records, and was told to submit another request or ask for the denial reason, but the concern was not tracked as a grievance because it was viewed as a quick resolution. The DON stated the representative’s concerns were discussed during the care plan meeting, but she did not recall all details and believed there was no need to file a grievance. The Administrator stated the facility denied access to the records because of an invalid address and what she believed was an invalid POA in the chart, and later found an old POA in storage naming the representative to make all health care decisions. The report also states the representative contacted law enforcement alleging the resident was injured by facility staff after incontinent care, and the DON said no grievance or self-report was made about that incident.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them for Resident #6. The resident was admitted and later readmitted with multiple diagnoses, including aftercare following surgery on the skin and subcutaneous tissue and Parkinson's disease with dyskinesia. On 5/26/26 at 10:27 AM, the resident stated he was unable to sleep because his roommate's TV was too loud and that the roommate was turning the heater on, making the room too hot and difficult to breathe. The resident said he had reported these concerns to the Social Worker three times, including that morning, but nothing had changed. Review of the facility's grievance file did not include the resident's concerns about his roommate. On 5/26/26 at 2:19 PM, the LSW stated the resident had expressed concerns about his roommate and that she spoke to the roommate, who denied turning on the heater. The LSW stated headphones were offered, but the roommate refused, and the resident said he would wear headphones only if the roommate did too. The LSW stated the resident raised the concern again that morning and it was not resolved. She also stated she failed to complete a grievance form for the resident and did not make a follow-up, acknowledging that she should have.
Incomplete grievance documentation and missing log entry
Penalty
Summary
The facility failed to provide complete documentation in response to a resident concern and failed to log concerns for one of three residents, Resident R53. The facility policy stated that grievances may be voiced in writing or orally, that the Grievance Official or designee is responsible for overseeing the grievance process and tracking grievances to conclusion, and that the Grievance Official or designee will investigate and provide follow-up within 72 hours. Resident R53’s Pink Encounter Form documented a report of an incident that occurred when Housekeeping Employee E8 made a comment to the resident in front of the resident’s visitor, but the section to be completed by facility staff was blank on review. The facility’s May 2026 Encounter Form Log also did not include Resident R53’s grievance. The Chief Nursing Officer confirmed that the facility failed to provide complete documentation in response to the resident concern and failed to log concerns for one of three residents.
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