Based on interview and record review. the facility failed to demonstrate that a grievance policy is in place for responding to recommended changes to facility policy and procedures and to provide an environment where residents felt comfortable reporting grievances to staff without fear of retaliation, for 3 of 3resident reviewed.
This is evidenced by:
1. During an interview on (date)at 9:35 am with Staff A and the Administrator by phone the following was revealed. The facility does not keep a written log of grievances and the residents come to the desk and tell them and they take care of it. Staff A conﬁrmed that the residents don‘t use the suggestion box. They come to the desk and tell the staff. The facility does not have any documentation or evidence of receipt or resolution of any grievances. The residents will tell her what the problem is and she will leave it on a sticky note for the Administrator who will take care of it. Staff A later presented a binder which she said was the grievance log, the information in the binder contained information dated between 2011 and 2015.