Failure to Document and Address Resident Grievances Communicated Through Ombudsman
Summary
The deficiency involves the facility’s failure to honor a resident’s right to voice grievances without discrimination or reprisal and to make prompt efforts to resolve those grievances. The facility’s grievance log from 01/01/2026 through 03/31/2026 contained no documented grievances for Resident #2, despite multiple written complaints submitted via the local Ombudsman. The Ombudsman sent 11 grievance emails to the Administrator detailing the resident’s concerns, including prolonged waits on a bedpan, ignored call lights, improper incontinent care, unaddressed pain and discomfort from leg wraps, food not being provided in a timely manner, and staff behavior perceived as rude, scolding, or yelling. None of these grievances were documented in the facility’s grievance records as required by the facility’s grievance policy. Resident #2 was a long-term care resident, a [AGE]-year-old female with diagnoses including hypertensive heart disease with heart failure and end-stage chronic kidney disease. She was dependent on staff for ADLs and transfers. The Ombudsman’s emails reported repeated instances where the resident stated she had been left on a bedpan for extended periods (ranging from approximately 25–50 minutes or more) and that her call light was not being answered. The Ombudsman also reported that the resident’s calls to the facility’s main number were not answered and that the voicemail box was full. Additional grievances included that a grilled cheese sandwich had been left on the resident’s dresser without being given to her, that leg wraps were too tight and painful and were not re-wrapped as promised by nursing staff, and that leg wraps coming off her feet were not tended to as requested. The Ombudsman further relayed grievances that specific CNAs and an LVN were providing care in ways the resident and her roommate found unacceptable. One CNA was reported to have cleaned the resident by wiping from rectum to vagina, which the Ombudsman identified as improper hygiene, and both the resident and her roommate requested that this CNA no longer attend to them. Another CNA was reported to repeatedly fail to respond to the resident’s call light or assist her off the bedpan, requiring another CNA from a different hall to help. The resident also complained that this CNA scolded her for using the call light. The Ombudsman reported that an LVN failed to return to re-wrap the resident’s leg after promising to do so and later allegedly yelled at the resident and accused her of tearing off her leg wraps, which the resident viewed as a violation of her dignity and respect. During interviews, the Administrator and DON acknowledged that Resident #2 had refused to allow them into her room and used the Ombudsman as her representative, and the Ombudsman stated that despite repeated verbal and emailed advocacy, the resident’s grievances were not addressed. The Administrator stated he had not documented any grievances from the Ombudsman’s emails, even though the facility’s grievance policy required the grievance official to receive, track, investigate, and document grievances and issue written grievance decisions to the resident. During an observation and interview, Resident #2 stated she was not being helped by staff, that her call lights were ignored, and that she was left on the bedpan for hours. She reported using her cell phone to call the facility without success and then calling the Ombudsman to complain. She reiterated that one CNA was rude and did not provide incontinent care properly or kindly and that she had requested this CNA no longer provide care to her, preferring another CNA instead. These statements, combined with the absence of any corresponding entries in the facility’s grievance documentation and the content of the Ombudsman’s emails, demonstrate that the facility did not follow its own grievance policy to document, investigate, and attempt to resolve the resident’s grievances, and did not ensure the resident’s right to voice grievances without fear of discrimination or reprisal was honored.
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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