Failure to Complete Unusual Occurrence Report After Resident-to-Resident Altercation
Summary
The deficiency involves the facility’s failure to follow its own Unusual Occurrence Report (UOR) policy after a resident-to-resident incident involving two residents with Alzheimer’s disease. An anonymous complaint to the State Agency alleged that one resident (R82) grabbed another resident’s (R90’s) head aggressively, that staff intervened, and that the Nursing Home Administrator later stated he had watched video and characterized the action as “petting” rather than an aggressive act. The complaint further alleged that this resident-to-resident incident was not reported by the facility as required. Record review showed that R82 had a diagnosis of Alzheimer’s disease and a Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 99/15, indicating severe cognitive impairment. R90 also had Alzheimer’s disease and an MDS BIMS score of 00/15, indicating cognitive impairment. Behavior charting in R82’s electronic medical record documented that on 12/06/2025 at 5:00 p.m., R82 exhibited aggression toward others, with additional information stating that the resident, while getting ready to eat dinner and standing next to R90, put his hands over her hair/eyes. This behavior entry was documented by LPN S. In an interview, the Nursing Home Administrator reported awareness of a situation between R82 and R90 about a month prior but stated he did not have a completed UOR for the event. In a separate interview, LPN S reported that on the date of the incident, R82 grabbed onto R90’s head and the two residents were immediately separated. LPN S stated that a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors, especially toward staff, but she was unsure whether the DON or any other staff member completed a UOR and confirmed that she did not complete one herself. Review of the facility’s UOR policy showed that resident-to-resident altercations are defined as unusual occurrences requiring completion and investigation of an Unusual Occurrence Report, including assessment, documentation, and follow-up, which was not done for this incident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to make grievance/complaint information available to 9 of 9 residents reviewed. Residents stated they did not know they could file anonymously, where to get a grievance form, who to give it to, what happened after filing, or that they had a right to a written decision. Observations showed the prominent postings did not include grievance instructions, and the ADM stated the grievance procedure and anonymous filing process were not being discussed in Resident Council.
Failure to Document and Investigate Resident Grievances: The facility did not consistently follow its grievance process for two residents. One resident reported missing clothing from laundry on more than one occasion and said staff told him they would notify the SW and management, but he received no further information. Another resident reported a missing wheelchair charger and said she was told the facility would not pay for it. The grievance logbook did not contain either concern, and the DOSS stated she had not written a grievance for the issue.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
A resident with multiple serious conditions and total dependence on staff for transfers and toileting repeatedly reported that two CNAs providing his care smelled strongly of marijuana and that he did not want them caring for him, while other residents and staff also reported ongoing strong marijuana odors on these CNAs and concerns about possible impairment. A unit manager and other staff acknowledged smelling marijuana on the CNAs, and the administrator was informed, but the facility’s grievance documentation lacked completed follow-up with the resident, and leadership confirmed that, beyond general staff education, no further action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, resulting in a failure to promptly and adequately resolve the grievance.
A cognitively intact, quadriplegic resident who was dependent on staff for ADLs reported that a CNA became upset when the call light was used and directed profanity toward the resident during care. The resident informed the AD the next day, stated the treatment and language were disrespectful, and requested to speak with the SSD. The AD texted the SSD about the complaint, but the SSD did not meet with the resident that day due to other duties and did not speak with the resident until two days later. This sequence of events shows the facility did not follow its grievance policy requiring the Administrator and staff to make prompt efforts to resolve grievances submitted orally or in writing.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 9 of 9 confidential residents reviewed for grievances. During interviews, all 9 residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not seen a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to submit it to, what happened after a grievance was filed, or that they had the right to receive a written decision once the grievance was resolved. Observation of prominent postings showed the facility did not include instructions regarding the grievance procedure with the postings. The ADM stated she was the grievance officer and that grievance forms were available on a shelf by the piano, but she did not know there were no forms available there. She stated the Activities Director completed grievance forms during monthly Resident Council meetings when concerns were voiced, and staff also completed forms for some face-to-face complaints. The ADM stated grievances were assigned to the appropriate department, addressed with the complainant, resolved, and documented on the grievance form, which was then reviewed and kept in a notebook for 3 plus years. The ADM also stated she was responsible for staff training on the grievance process and agreed the availability of grievance forms, the grievance procedure, and the process for submitting an anonymous grievance should be explained at admission and continually discussed in monthly Resident Council meetings.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to consistently implement its grievance procedures and failed to document, investigate, track, and follow up on resident grievances for two residents. One resident reported that clothing items had gone missing from the laundry on more than one occasion and stated the items were marked with his name. He said he reported the missing clothing to two staff members, who told him they would notify the social worker and management, but he did not receive any further information. A CNA stated that missing clothing concerns would be reported to the Charge Nurse or Social Worker, but she was not aware of how to obtain or assist a resident with a grievance form. A second resident stated during a Resident Council Meeting that the charger for her wheelchair was missing and that a staff member took it. She said she informed the facility and was told they would not pay for it. The Director of Social Services stated a search was done and a new charger would be ordered, but she had not written a grievance about the issue. The Administrator stated the Director of Social Services was responsible for grievance management, and the Director of Social Services stated she was not aware of a grievance from the first resident. Review of the grievance logbook for 2025 and 2026 confirmed that neither resident’s concern was documented. The facility policy required oral or written grievances to be investigated by Social Services, with findings reported to the Administrator within five working days and the resident informed within ten working days.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Promptly Resolve Grievances About Staff Smelling of Marijuana and Incomplete Grievance Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and resolve a resident grievance regarding staff smelling of marijuana while providing care, and to properly document and follow up on that grievance. One resident with intact cognition and significant physical dependence on staff for activities of daily living reported that two CNAs providing his care smelled strongly of marijuana. This resident, who had multiple serious medical diagnoses including panlobular emphysema, COPD, dependence on a respirator, heart failure, type 2 diabetes, muscle wasting, insomnia, and anxiety, stated that the odor was so strong it upset him and caused him to feel he could not trust these CNAs to safely use a mechanical lift for his transfers. He reported his concerns to multiple facility staff, including the DON, ADON, scheduler, and social services designee, and indicated that this was not the first time he had raised the issue. Facility documentation showed that a unit manager completed a witness statement after the resident reported that two CNAs smelled like marijuana. The unit manager documented that she could smell a faint odor of marijuana on the CNAs, although she did not believe they appeared impaired, and she told them it was not appropriate to come to work smelling like marijuana. A resident concern/complaint form and a resident/family grievance form were completed, indicating that the administrator spoke with the evening supervisor and that the CNAs were told they were not to smell like marijuana. However, the grievance form’s follow-up section, which should document the name and date of the individual contacted, comments, and the staff member completing follow-up with the resident or family, was left blank. The DON later verified that the grievance documentation was incomplete. Multiple residents and staff corroborated ongoing concerns about staff smelling of marijuana. Another cognitively intact resident reported that one CNA always smelled of marijuana, that the odor was very strong, and that the CNA moved very slowly while providing care, causing concern that she might be impaired. This resident stated that both CNAs smelled of marijuana on more than one occasion and that the odor was noticeable even when they were behind the nurse’s station. A third resident reported that residents at council meetings had stated they smelled marijuana in the building and on staff, and that residents had informed administration of these concerns as an ongoing problem. Several CNAs and an LPN reported smelling marijuana odor on the same CNAs while they were working, with one CNA stating she believed they were working impaired based on incomplete work from the prior shift, and another CNA reporting she had seen them vaping a substance with a strong marijuana odor during breaks and had reported this to the night unit manager. The scheduler and social services designee confirmed that the primary resident had texted them about the CNAs smelling of marijuana and that they had notified the administrator and nursing leadership. The DON acknowledged that the facility was a drug-free workplace and that smelling of marijuana constituted reasonable suspicion for testing, and further acknowledged that, aside from general staff education, no additional corrective action was taken to ensure the CNAs were not working while smelling of marijuana or possibly impaired, and that grievance follow-up with the resident was not completed or documented.
Failure to Promptly Address Resident Grievance About Disrespectful CNA Behavior
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint filing policy requiring the Administrator and staff to make prompt efforts to resolve resident grievances. A resident with quadriplegia and other neurologic and musculoskeletal conditions, who was cognitively intact and dependent on staff for ADLs, reported that a CNA became upset when the resident pressed the call light and used profanity (“f***”) while providing ADL care. The resident stated this occurred in the evening and that he felt the CNA’s language and behavior were disrespectful. The next day, the resident reported this incident to the Activities Director (AD), stating he did not like how the CNA treated him and that the language used around him was disrespectful, and he requested to speak with the Social Services Director (SSD). The AD acknowledged that the resident reported the CNA’s use of the F word during care and that such behavior was not acceptable. The AD texted the SSD the same day, informing her that the resident wanted to speak with her regarding a complaint involving a nurse, and the SSD responded that she was in a meeting. The AD did not know whether the SSD spoke with the resident or whether the Administrator was informed. The SSD later stated she did not see the resident that day because she was very busy with new admissions and meetings and did not have the opportunity to speak with the resident until two days later. The DON stated that resident complaints should be addressed immediately and grievances resolved in a timely manner. The facility’s written grievance policy stated that the Administrator and staff will make prompt efforts to resolve grievances submitted orally or in writing, but in this case the resident’s grievance about staff behavior and language was not promptly addressed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.