§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 provided documentation, it was determined that the facility failed to address residents' concerns related to late call bell response time three of six residents reviewed. (Resident R3, R4, R5)
Findings include:
During interview with Resident R3, on Monday, December 1, 2025 at 11:10 am, room 224-A, he reported waiting excessively long time for response from nursing staff during overnight shifts, 11 pm to 7 am.
Review of facility provided grievance reports for month of November 2025 revealed care concern was submitted on November 2, 2025 regarding Resident R4, and untimely hygiene care; unidentified shift.
Further review of grievance reports revealed care concern was submitted on November 2, 2025, regarding Resident R5 and call bell response time; unidentified shift.
Further review of facility report submitted to the State Survey Agency, dated November 18, 2025, revealed Resident R5's concern related to "waiting long periods for care, and not cleaned properly after being soiled"; unidentified shift.
Review of facility provided call bell audits for month of November 2025 revealed that audits were mainly completed during day and evening shifts, unidentified times, and excluding room #'s from which concerns were reported.
Further review of call bell audits, dated November 22, 2025, revealed unidentified shift and time, noting one hour wait time for call bell response from 2:30 pm to 3:30 pm.
28 PA Code 201.18(b)(3) Management
| | Plan of Correction - To be completed: 01/06/2026
Facility could not retroactively correct the deficiency to late call bell response times for Resident R3, R4 and R5.
Call bell audits were completed and presented citing the hallways/sections in which Residents R3, R4 and R5 resided.
An initial audit will be completed ensuring that resident concerns citing care, and call bell response times are addressed, and that residents do not wait for excessively long periods for response from nursing staff during overnight shifts, 11pm to 7am.
NHA/DON or designee will educate nursing staff on call bell response to ensure that concerns regarding care, and call bell response times are addressed to ensure that residents do not wait for excessively long periods for response during overnight shifts, 11pm to 7am.
Concierge or designee will complete call bell audits weekly x4 then monthly x2, inclusive of overnight shifts, 11pm to 7pm, to ensure that residents are not waiting for excessively long periods for a response.
Results of the audits will be presented at the QAPI meeting for review.
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