Failure to Timely Resolve Resident Grievances About Missing Clothing
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances related to missing clothing, as required by its grievance policy and resident rights regulations. The written policy, last revised May 8, 2025, states that grievance reviews must be completed within 30 days and that any resident rights violation must be corrected within 10 days or referred to the State Department of Health if it cannot be corrected within that timeframe. During a Resident Council group interview, multiple residents reported that grievances were not always resolved timely or at all. Residents specifically reported missing clothing items for which grievances had been filed but that had not been found or replaced. One resident reported missing a pair of pants since January 2026, and another reported missing three pairs of brand-new slacks and two shirts, stating that staff took them from his room and never returned them. Review of a Concern Form dated November 11, 2025, showed that several residents had reported not getting their clothes back, despite most items being labeled with their names. The missing items included a sweat suit and sports bras for one resident, pajama sets and gripper socks for another, sweatshirts and dress pants for a third, and a new pair of jeans for a fourth. Documentation of the resolution dated November 13, 2025, indicated the concern was not resolved, as only some laundry was returned and other items were still being searched for, leaving the residents dissatisfied. In a subsequent interview, the DON was unable to provide any additional information on further efforts to locate the missing clothing, whether the items had been replaced, or whether any follow-up or grievance documentation existed for the residents who reported missing clothing during the Resident Council meeting. These findings demonstrate that the facility did not follow its own grievance policy time frames or ensure timely resolution of the residents’ grievances regarding missing clothing.
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