§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, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in three of three locations where grievances boxes are located (main lobby, north and south nursing units).
Findings include:
A review of the facility policy "Grievances/Complaints, Filing" reviewed 1/16/25, grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.
The Centers for Medicare &; Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA).
In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement.
To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents.
During a resident group interview, on 2/11/26 at approximately 11:30 a.m., when asked if they felt they could anonymously file a grievance in the grievance boxes, consensus from the group was "no". Residents stated, there a couple of boxes "they are too high to reach", "they are not made for people in wheelchairs", the boxes are in view of the staff, and "you have to ask someone to help you, so we just ask the staff to do it for us".
During an observation and interview on 2/12/26, at 9:00 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes; the lobby height was 54 inches, north nursing unit box height was 53 inches, and south nursing unit box, height was 57 inches. The box in the lobby was in view of the reception desk and blocked by a chair, the north nursing unit box was in view of the nursing station, and the south nursing unit box was blocked by a cart with a cooler in front of it and the box is in view of the nursing station.
During an interview on 2/12/26, at 9:00 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents.
28 PA Code: 201.18(e)(4) Management.
28 PA Code: 201.29(a)(b)(c) Resident rights.
| | Plan of Correction - To be completed: 03/30/2026
I. The grievance boxes will adjusted to ADA standards at the time of the surveyors observation.
II. Facility grievance boxes will be at ADA height standards.
III. Nursing Home Administrator will re-educate Maintenance Director that grievance boxes must be at ADA height standards.
IV. Nursing Home Administrator/designee will audit grievance boxes monthly to ensure they are at ADA height standards. Audit results will be taken through Quality Assurance for tracking and trending purposes.
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