Failure to Address Grievance Regarding Hoyer Transfers
Summary
The facility staff failed to implement their policy and provide appropriate and timely resolution to a grievance concerning safe Hoyer transfers for a resident. The resident, who had severe cognitive impairment and required total assistance for all activities of daily living, was observed being transferred by a single staff member using a Hoyer lift on two separate occasions. Despite the resident's daughter reporting these incidents and providing video evidence, the facility did not promptly identify or counsel the staff involved. The Director of Nursing (DON) acknowledged the issue but did not take immediate action to identify the staff members or ensure proper training and documentation of the incident. The grievance was initially reported on 03/11/24, and subsequent videos were provided on 03/25/24 and 04/01/24. The DON observed the videos on 04/02/24 and posted a sign in the resident's room, but the sign was deemed inappropriate by the Administrator. The facility's Human Resource Manager later identified the staff members involved, but there was no evidence of counseling or disciplinary action in their employee files. The facility's policies required at least two staff members for Hoyer transfers and mandated timely investigations of compliance issues, which were not followed in this case.
Penalty
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A resident with multiple serious conditions and total dependence on staff for transfers and toileting repeatedly reported that two CNAs providing his care smelled strongly of marijuana and that he did not want them caring for him, while other residents and staff also reported ongoing strong marijuana odors on these CNAs and concerns about possible impairment. A unit manager and other staff acknowledged smelling marijuana on the CNAs, and the administrator was informed, but the facility’s grievance documentation lacked completed follow-up with the resident, and leadership confirmed that, beyond general staff education, no further action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, resulting in a failure to promptly and adequately resolve the grievance.
The facility failed to properly document, investigate, and resolve grievances from residents and families. Concern logs contained only minimal information and listed resolution dates without supporting documentation. A cognitively intact resident dependent on staff for toileting reported long delays in call light response and remaining wet with urine despite a logged concern about response time. A family member’s complaint about a resident’s daily routine and another family’s report of missing clothing were logged, but there was no evidence in the records of investigation or follow-up, and required concern forms were not completed. Staff interviews showed confusion over responsibility for handling grievances and confirmed the absence of a policy for non–missing-item concerns.
The facility did not provide residents with information about the grievance process or how to file a grievance. Multiple residents, including those who were cognitively intact and involved in resident council, were unaware of their rights or the process, and staff also lacked knowledge. No information was posted in the facility, despite policies requiring residents be informed and assisted in filing grievances.
Residents reported and records confirmed significant delays in call light response times, with some waiting over an hour for assistance. Despite staff education on timely response, there was no evidence of follow-up or monitoring, and grievances about the issue remained unresolved, affecting multiple residents.
The facility did not address or follow up on 30 out of 75 resident grievances and multiple concerns raised during Resident Council meetings, including issues with medication administration, food quality, staffing, and care preferences. Documentation and follow-up actions were inconsistent, and interviews with the DON and Administrator confirmed that required grievance procedures were not followed.
A resident's family reported a missing lamp, which was removed from the room by staff and later found in the maintenance office. The facility did not document or address the grievance in accordance with its policy, and there was no evidence of a timely investigation or resolution.
Failure to Promptly Resolve Grievances About Staff Smelling of Marijuana and Incomplete Grievance Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and resolve a resident grievance regarding staff smelling of marijuana while providing care, and to properly document and follow up on that grievance. One resident with intact cognition and significant physical dependence on staff for activities of daily living reported that two CNAs providing his care smelled strongly of marijuana. This resident, who had multiple serious medical diagnoses including panlobular emphysema, COPD, dependence on a respirator, heart failure, type 2 diabetes, muscle wasting, insomnia, and anxiety, stated that the odor was so strong it upset him and caused him to feel he could not trust these CNAs to safely use a mechanical lift for his transfers. He reported his concerns to multiple facility staff, including the DON, ADON, scheduler, and social services designee, and indicated that this was not the first time he had raised the issue. Facility documentation showed that a unit manager completed a witness statement after the resident reported that two CNAs smelled like marijuana. The unit manager documented that she could smell a faint odor of marijuana on the CNAs, although she did not believe they appeared impaired, and she told them it was not appropriate to come to work smelling like marijuana. A resident concern/complaint form and a resident/family grievance form were completed, indicating that the administrator spoke with the evening supervisor and that the CNAs were told they were not to smell like marijuana. However, the grievance form’s follow-up section, which should document the name and date of the individual contacted, comments, and the staff member completing follow-up with the resident or family, was left blank. The DON later verified that the grievance documentation was incomplete. Multiple residents and staff corroborated ongoing concerns about staff smelling of marijuana. Another cognitively intact resident reported that one CNA always smelled of marijuana, that the odor was very strong, and that the CNA moved very slowly while providing care, causing concern that she might be impaired. This resident stated that both CNAs smelled of marijuana on more than one occasion and that the odor was noticeable even when they were behind the nurse’s station. A third resident reported that residents at council meetings had stated they smelled marijuana in the building and on staff, and that residents had informed administration of these concerns as an ongoing problem. Several CNAs and an LPN reported smelling marijuana odor on the same CNAs while they were working, with one CNA stating she believed they were working impaired based on incomplete work from the prior shift, and another CNA reporting she had seen them vaping a substance with a strong marijuana odor during breaks and had reported this to the night unit manager. The scheduler and social services designee confirmed that the primary resident had texted them about the CNAs smelling of marijuana and that they had notified the administrator and nursing leadership. The DON acknowledged that the facility was a drug-free workplace and that smelling of marijuana constituted reasonable suspicion for testing, and further acknowledged that, aside from general staff education, no additional corrective action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, and that grievance follow-up with the resident was not completed or documented.
Failure to Document and Resolve Resident and Family Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without reprisal and to make prompt efforts to resolve those grievances, as required by its own policies and regulatory expectations. Review of the facility’s Concern Tracking Logs showed that entries only included the date, resident name, general nature of concern, department, and a listed date of resolution, without specific details of the concerns or documented follow-up. For three residents reviewed, there was no documented evidence of investigation or resolution beyond the brief log entries. One resident, who was cognitively intact and always incontinent of bowel and bladder and dependent on staff for toileting, had a concern logged about response time on a specific date, with the same date listed as the resolution date. However, the resident later reported waiting 2–4 hours for call lights to be answered and lying in urine for long periods, and there was no documentation showing how his concern had been addressed or resolved. A second resident’s daughter submitted a concern regarding the resident’s daily routine, which was logged with a resolution date the following day, but the medical record contained no documentation of the concern or any resolution. The resident was transferred to the hospital the next day due to a change in condition and did not return, and there was no documented evidence of follow-up on the grievance. For a third resident, a family concern about missing clothes was logged with a resolution date, but there was no Resident Concern Form completed and no evidence of an investigation, despite a facility policy requiring prompt investigation, documentation on a Resident Concern Form, and follow-up by the Social Services Director. Interviews with the Social Services Coordinator and the Administrator revealed conflicting understandings of who was responsible for handling missing item reports and concerns, that no concern forms had been completed for these three residents, and that the facility lacked a policy for following up on resident concerns that were not related to missing items.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide residents with information regarding the grievance process and how to file a grievance, as required by policy. Record review and interviews revealed that three residents, including one who was cognitively intact and served as the presiding president of the Resident Council, were unaware of their right to file a grievance or the process for doing so. These residents reported that the grievance process had never been explained to them individually or during resident council meetings. One resident with moderate cognitive impairment also indicated he was unaware of the process and could not recall it being discussed at meetings he attended. Further investigation showed that there was no posted information about the grievance process in the facility, and the Assistant Director of Nursing confirmed a lack of knowledge about how the process worked. Although the Administrator was able to provide a written policy and the names of the grievance committee members, there was no evidence that this information was communicated to residents. The facility's own policies stated that residents have the right to file grievances orally or in writing and that the facility should assist residents in exercising this right, but these procedures were not being followed or made known to residents.
Failure to Resolve Resident Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to ensure that resident grievances regarding the timely answering of call lights were resolved appropriately and within a reasonable timeframe. Multiple records, including in-service documentation, grievance logs, and resident council minutes, indicated ongoing concerns about delayed call light responses. Specific incidents were documented where residents waited extended periods, ranging from over 26 minutes to more than two hours, for their call lights to be answered. Residents consistently reported long wait times during interviews, and the issue was also raised during resident council meetings. Despite staff being in-serviced on the importance of timely call light response, there was no evidence of follow-up audits or monitoring to ensure compliance. The facility's grievance policy required immediate action to prevent further violations of resident rights, but the lack of timely resolution and monitoring led to repeated and unresolved complaints from residents. This deficiency affected nine residents and was substantiated through multiple sources, including direct resident interviews and review of facility records.
Failure to Address and Follow Up on Resident Grievances and Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident grievances and concerns in a timely manner, as evidenced by a review of facility documents, staff interviews, and policy review. Out of 75 grievances filed between April 2025 and September 2025, 30 had not been followed up on. Additionally, multiple concerns raised during Resident Council meetings from June through October 2025—including issues with untimely medication administration, undercooked food, staffing, staff approach, and showers—were not addressed or followed up on. The facility census at the time was 70 residents, indicating that the failure had the potential to affect all residents. Further review revealed inconsistencies in documentation and follow-up actions. For example, meeting minutes from August 2025 indicated that an LPN had been counseled for untimely medication administration, but the personnel file contained no documentation to support this. Interviews with the DON and Administrator confirmed that the grievances and concerns had not been addressed as required by facility policy, which designates the Administrator as the Grievance Official responsible for oversight and written decisions. The facility's policy also requires action and communication regarding Resident Council concerns, which was not followed.
Failure to Timely Address and Document Resident Grievance Regarding Personal Property
Penalty
Summary
The facility failed to document and address a grievance made by a resident's representative in a timely manner. A resident, who was cognitively intact and had multiple complex medical diagnoses, was discharged to the hospital for ongoing medical issues. During his stay, the resident's family reported a missing lamp, which was later found in the facility's maintenance office. The lamp had been removed from the resident's room by the Plant Operations Director after it was discovered that it was plugged into an extension cord. The Plant Operations Director informed the resident about the removal, but there was no documented response from the resident. The family left a note on the resident's door requesting the return of the lamp, and the Administrator acknowledged being aware of this request. However, the Administrator did not return the lamp to the family and was unable to provide documentation of any grievance investigation, resident concern form, or resolution to the grievance. The facility's policy required concerns to be entered electronically and resolved within 24-48 hours, but there was no evidence that this process was followed in this case.
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