§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.
§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.
§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.
§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
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Observations:
Based on review of facility policy, resident interviews and staff interviews, it was determined the facility failed to make prompt efforts to resolve resident verbal grievances regarding delayed call light response times for six of twelve residents reviewed (Residents 1, 2, 3, 4, 5, and 6).
Findings include:
A review of the facility's "Grievance Policy" last reviewed on July 29, 2025, indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official follow up on all concerns and grievances registered by any resident or resident representative.
A review of the facility policy titled " Answering the Call Light, " last reviewed September 2025, indicated staff are responsible for responding to resident call lights in a timely manner. If immediate assistance cannot be provided, staff are to inform the residents of the approximate response time. The policy indicated staff should complete requests promptly whenever possible, seek assistance from the nurse supervisor if unable to fulfill a request, and document any significant resident requests or complaints, including how the concern was addressed.
During resident interviews conducted on July 14, 2026, six residents reported they had verbally complained to nursing staff regarding prolonged call light response times; however, the delays continued without resolution.
During an interview on July 14, 2026, at 9:00 AM, Resident 1, who had a BIMS (Brief Interview for Mental Status, a standardized assessment of cognition, memory, attention, and orientation, a score of 13 to 15 indicates intact cognition) score of 15, indicating she was cognitively intact, stated she routinely waited more than 30 minutes after activating her call light. She stated staff frequently responded by saying the facility was " short staffed, " turned off the call light, advised they would return, and often did not return for an additional 30 to 45 minutes, particularly when she needed assistance to the bathroom. Resident 1 stated she continued to experience the same delays despite reporting her concerns.
During an interview on July 14, 2026, at 9:05 AM, Resident 2, who had a BIMS score of 15, stated she frequently waited approximately 45 minutes for assistance after using her call light. She stated staff commonly attributed the delay to being " short staffed, " turned off her call light after acknowledging it, advised they would return, and did not provide assistance for more than 30 minutes. She stated these delays were especially difficult when she needed assistance toileting. She stated the problem continued despite bringing concerns to staff.
During an interview on July 14, 2026, at 9:10 AM, Resident 3, a cognitively intact resident with a BIMS score of 14, was lying in bed. She stated that she had not received her breakfast yet because she had to wait for nursing staff to get to her. She stated that she had been waiting after ringing the call bell for more than 30 minutes. She also stated that she often waits more than 30 minutes for assistance when she rings the call bell. Resident 3 stated prolonged delays continued despite reporting her concerns.
During an interview July 14, 2026, at 9:15 A.M., Resident 4, a moderately, cognitively impaired resident with a BIMS score of 10 (score of 8 to 12 indicates moderate cognitive impairment), stated that she waits more than 30 minutes for staff assistance when she rings the call bell. She stated that staff tell her that the facility is " short staffed " . She stated that staff will answer her call bell, turn it off and state that they will return to help her, the wait is greater than 30 minutes. Resident 4 stated the delays continued after she reported her concerns.
During an interview on July 14, 2026, at 9:20 A:AM, Resident 5, a cognitively intact resident with a BIMS score of 15, stated that she waits more than 30 minutes for assistance when she rings the call bell. She stated that staff tells her that they are " short staffed " . She stated that staff will often answer the call bell, immediately turn the bell off and state to the resident that they will be back to assist her. The resident stated that staff do not return timely, it is sometimes greater than 30 minutes. Resident 5 stated no improvement occurred after she voiced her concerns.
During an interview July 14, 2026, at 9:45 AM, Resident 6, a moderately, cognitively resident with a BIMS score of 11, stated she had waited as long as one and one-half hours for assistance with toileting. She stated that she recently fractured her knee, is currently receiving physical therapy services and cannot ambulate independently to the bathroom for toileting. She stated that nursing staff often tells her that the facility is short staffed and she must wait for assistance. She stated that it is very hard to wait for long periods for assistance for toileting. She stated she continued to experience prolonged delays despite reporting her concerns to staff.
The facility was unable to provide documentation or other evidence demonstrating it investigated, followed up on, or made efforts to resolve the residents ' verbal grievances regarding delayed call light response times in accordance with its grievance policy through the conclusion of the survey on July 14, 2026.
During an interview on July 14, 2026, at 9:10 AM the Nursing Home Administrator confirmed the residents' verbal grievances regarding delayed call light response times had not been resolved.
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 201.29(a) Resident Rights.
28 Pa. Code 211.10 (d) Resident care policies.
| | Plan of Correction - To be completed: 08/04/2026
1. Facility cannot retroactively correct the alleged deficiency of call bells not being answered timely.
2. NHA/designee to review last week of call bell audits as well as conduct interviews with alert and oriented residents to confirm call bells are being answered and resident needs are being met.
3. NHA/designee to re-educate staff on call bell policy.
4. NHA/designee to audit 5 call bell response times weekly x 4 and monthly x 2 to confirm compliance. Results will be brought to monthly QAPI meeting.
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