§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 observation, a review of select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities, including six out of six residents interviewed during a resident group meeting (Residents 46, 56, 71, 77, 83, and 94).
Findings included:
A review of the facility policy titled "Resident and Family Concerns," last reviewed by the facility on January 21, 2026, revealed it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. Information on how to file a grievance or complaint will be available to the resident.
A review of the facility policy titled "Resident and Family Concerns" revealed the facility failed to include the following required information in the policy: the contact information of the grievance official, the contact information of independent entities with whom grievances that may be filed, and the time frame that residents may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance.
During a resident group interview on January 28, 2026, at 10:00 AM, six out of six alert and oriented residents (Residents 46, 56, 71, 77, 83, and 94) in attendance indicated they were not informed about the facility grievance process and did not know how to file a grievance. The residents in attendance were unable to explain the grievance process or purpose. Residents 46, 56, 71, 77, 83, and 94 were unable to identify the grievance official and did not know how to file a grievance or how to file a complaint with independent entities such as the local ombudsman or pertinent state agencies.
An observation on January 28, 2026, at 10:45 AM of the third-floor dining room revealed an unlabeled black mailbox. There was no information explaining the function or purpose of this box.
During an interview on January 28, 2026, at 10:55 AM, Employee 3, LPN, confirmed there was an unlabeled black mailbox in the third-floor dining room. She explained that she believed the box was for resident grievances. Employee 3, LPN, confirmed there was no posted information explaining the function or purpose of the box.
During an interview on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The NHA was unable to explain why Residents 46, 56, 71, 77, 83, and 94 indicated they had no knowledge of the grievance process. The facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities.
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 201.29(a) Resident rights.
| | Plan of Correction - To be completed: 03/10/2026
The facility corrected the cited deficiency by reposting the grievance posters/forms on each nursing unit.
The SSD or designee will review the Grievance process and location of Grievance forms/boxes with Residents during Ad hoc resident council meeting.
The SSD/designee will re-educate staff on the resident grievance policy and grievance form which will be used to document concerns expressed in resident council. The Grievance policy will be reviewed during the next resident council and will be posted in the center. Grievances from the resident council (or any other source) will be given to both the grievance officer (Social Service Director), the Administrator, and the department head responsible for response to the concern ensuring a timely response.
The Administrator/designee will audit grievances and informational posters weekly x 4 weeks, then monthly x 3 months. The results of these audits will be brought to the facility QAPI meeting monthly for further review and recommendations.
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