Failure to Offer and Process Written Grievances for Care and Medication Concerns
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and their representatives were afforded the right to file grievances and have those grievances formally investigated and resolved in writing, as required by facility policy and regulation. The facility’s Resident Rights policy dated 09/2022 stated that residents had the right to voice grievances about care or services and could expect prompt investigation and attempts at resolution. For one resident with Alzheimer’s dementia and diabetes mellitus, the MDS dated 12/08/2025 showed severe cognitive impairment and family participation in assessment and discharge planning. Medical and social work documentation from late December 2025 and January 2026 showed that the resident’s representative expressed concerns about the resident’s medication regimen, specifically the continued use of Klonopin despite the representative’s request to discontinue it, and that these concerns were discussed in care plan meetings with the IDT and the Administrator. However, there was no documented evidence that the representative was offered the opportunity to file a written grievance regarding these care and medication concerns. The deficiency also involved another resident with Parkinson’s disorder and depression, whose MDS dated 12/18/2025 documented short-term memory deficits but independence in decision-making, a history of falls in the prior two to six months, and a need for partial/moderate assistance with toileting. Nursing and social work notes from December 2025 documented the resident’s request not to have a specific CNA assigned due to the aide’s skin color and an incident in which the resident demanded latanoprost eye drops be administered at times differing from the MD order. The resident’s representative later reported concerns about the resident’s medication regimen and number of falls, and stated these concerns had not been addressed or resolved. There was no documentation that the resident or representative was offered the opportunity to file a written grievance for unresolved care and medication concerns. In interviews, the assigned social worker and the Administrator acknowledged that concerns were handled through care plan meetings and communication, and that written grievances were not initiated or documented for either resident, and no grievance investigations were on file for them.
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