F0585

E

Failure to Address Resident Grievances on Call Light Response and Laundry/Personal Belongings

Wheaton, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without reprisal and to establish and implement an effective grievance process, specifically regarding call light response times and laundry/personal belongings. A resident representative reported that one resident’s call light responses often took 15–20 minutes, leading the resident to attempt to toilet independently to avoid accidents; the resident confirmed this account. Another resident reported that staff sometimes took an hour to respond to his call light, with occasions of no response, and stated he used his call light or cell phone to request assistance and wore pullups due to bed sores. The DON acknowledged receiving call light concerns approximately once per week, including complaints from the Ombudsman, and stated such concerns should be documented on grievance forms and followed up on, but could not provide evidence of follow-up or documentation. Review of grievances from December 2025 through March 2026 showed no reports, findings, or resolutions related to poor call light response times.

The facility also failed to address and document grievances related to laundry and missing personal items. A resident representative stated that one resident’s family had been doing her laundry due to missing items, including comforters in winter, and both the representative and resident reported that clothing sometimes went missing; the resident’s clothes at bedside were not labeled, and no inventory beyond admission was found in the record. The same representative reported that other residents’ clothes were routinely returned to another resident’s room, that something of that resident’s was missing every week, and that this was a common issue; the resident confirmed missing items from laundry, and the facility had only attempted to inventory her belongings about six months after admission with no subsequent updates. Another resident reported missing clothes, seeing other residents wearing his shirts, and missing about five pairs of shoes; his record contained no admission inventory or documentation that he declined an inventory. A fourth resident reported issues with clothes being returned from laundry and stated he had reported this to nurses.

Staff interviews and facility documents further demonstrated unaddressed grievances and inadequate protection of personal property. A CNA reported recent issues with missing items from laundry related to laundry staff turnover, and another CNA stated she had received resident complaints about not receiving their clothes, noting that the former permanent laundry aide had left and new staff were unfamiliar with residents’ clothing, although she stated that residents’ clothes were labeled. Resident council minutes from December 2025 documented concerns about clothes not being returned correctly due to laundry staff not reading labels, and minutes from January and February 2026 documented concerns about clothes going to the wrong rooms and missing from laundry. A grievance form dated 02/21/2026 included Ombudsman-reported concerns about a resident’s missing items. The DON and ADON stated that the facility had an inventory form to be completed on admission and uploaded to the chart, that refusals should be documented, and that families were educated to label belongings or the facility would do so, and the DON acknowledged prior staffing issues in laundry and ongoing clothing return problems over several months. The facility’s Resident Rights Policy required reasonable care to protect personal property from loss, and the Grievance Policy required investigation and written findings to the administrator within five working days of receiving a written grievance, but the surveyors found no documentation showing that reported concerns about call lights or laundry were consistently documented, investigated, or resolved.