F0585

D

Failure to Initiate and Communicate Formal Grievance Process for Hygiene Care Concerns

Long Beach, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and to assist a resident and the resident’s responsible party (RP) in filing and processing a formal grievance regarding inconsistent showering and hygiene care. The resident, who was admitted with hepatic encephalopathy, type 2 DM, and legal blindness, had a Minimum Data Set (MDS) indicating moderately impaired cognition but an ability to understand and be understood, and a need for partial to moderate assistance with ADLs. The facility’s policy required staff who overhear or receive a grievance or complaint from a resident or representative to encourage and facilitate completion of a Grievance/Complaint Investigation Report, initiate an investigation, and inform the resident and RP of findings and corrective actions, with all written grievances recorded on the grievance log.

The RP reported that during visits in a specified month, the resident appeared in dirty clothes, sitting on dirty bed linens, and not groomed, and that on the resident’s birthday the resident was not showered or prepared for an outing despite the RP’s expectations. The RP stated she attempted multiple times to reach the Social Services Director (SSD) about these concerns but found the SSD difficult to reach and unresponsive. On another occasion, the RP called an LVN the evening before a medical appointment, emphasized the importance of the resident being showered and ready, and was assured this would occur; however, when she arrived the next morning, the resident was in dirty clothes and eating breakfast. The RP reported feeling emotionally stressed, frustrated, and distrustful, ultimately calling law enforcement to make a police report, and stated that the facility did not inform her of the grievance process and did not respond to her complaints or the police report until she filed a complaint with the state survey agency.

During observation, the resident was seen lying in bed wearing a stained T‑shirt on bedsheets that appeared stained with gray material and appeared ungroomed. The resident reported frustration about not being able to shower regularly, stating staff did not consistently assist him to the shower and sometimes only provided a towel for washing up. He stated that, as a legally blind person, he needed assistance gathering clothes and supplies and being led to the shower, and that staff accused him of refusing showers, which he denied, saying he would like to shower daily. He reported that he had tried to reach out to the SSD about his complaints, that she did not follow up with him daily, and that he asked his RP to make complaints and grievances on his behalf, but he had not heard a response from the facility regarding these concerns.

Record review showed the resident’s bathing log listed scheduled showers on Tuesdays and Fridays, but between two specific dates in February, a 13‑day period, the resident received only one shower, with no documentation of shower refusals. An IDT note dated later in February documented that the team discussed the resident’s and RP’s concerns about lack of showering and characterized the resident as providing exaggerated and inconsistent accounts of care, and also noted generalized body dermatitis on a physician assessment, but there was no documentation that the resident’s allegations were investigated or that outcomes were communicated to the resident or RP. The MDS nurse confirmed that the bathing log showed only one shower in that period and no refusals, and that the IDT note reflected discussion of the concerns without documented follow‑up or resolution communicated to the resident or RP.

The SSD stated that as of early March there were no grievances filed by the resident or RP on the grievance log from December through February and that she was not aware of any outstanding grievances. The DON acknowledged being aware of the concerns raised by the resident and RP at the IDT meeting and of the RP’s complaint that the resident did not receive a shower on a specific date, which led to the RP calling the police alleging lack of care. The DON stated the facility did not enter the resident’s and RP’s allegations regarding lack of showers into the grievance log to initiate the grievance process. She also stated that the SSD did not provide a copy of the grievance report related to the police report to the state agency because the facility was still working on completing the grievance form, and that the facility only provided a verbal update to the RP and did not provide the update in writing. The DON stated that failing to follow the facility’s grievance process can result in unresolved issues and resident/RP concerns, and that facility policy requires investigation and resolution of all grievances with clear communication of outcomes to residents and their representatives.