Morningside Nursing and Rehabilitation Center
March 21, 2025 Complaint Survey

Standard Health Citations

FF15 483.10(j)(1)-(4):GRIEVANCES

REGULATION: 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Abbreviated Survey (NY 289), the facility failed to ensure residents had the right to obtain a written decision regarding their grievance. This was evident for one (1) of three (3) residents sampled (Resident #1). Specifically, on 11/24/2024, 01/24/2025, 01/28/2025, and 02/27/2025, Resident #1's Health Care Proxy requested written results for the filed grievances. The request was sent on an e-mail to the Administrator. The written results were not provided to Resident #1's Health Care Proxy. The findings are: The facility policy titled, Grievance/Complaint Policy, dated 11/17/2017, documented the facility shall establish written policies and procedures to process all complaints and recommendations initiated by individual patients/residents, their Designated Representatives or family members, as well as by the Resident Council in the general forum. The facility will notify the resident individually or through posting in prominent locations throughout the facility of the right to obtain a written decision regarding his or her grievance. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 03/18/2024 identified Resident #1's cognition as severely impaired. An Email dated 11/24/2024 was sent to the Facility Administrator documented Resident #1's Health Care Proxy requested written confirmation of the steps being taken regarding their parent being found on multiple occasions wet and soiled. A review of the Grievance /Complaint Form dated 01/12/2025, sent via email to the Facility's Administrator documented Resident #1 Health Care Proxy filed a grievance about their parent being found with wet, incontinent brief and pants. A review of the Grievance/Complaint Form dated 01/24/2025, was sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested written confirmation detailing how an Unlicensed Social Worker diagnosed medical conditions, will be addressed. A review of the Grievance/Complaint Form dated 01/28/2025, sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested a written response on their grievance regarding Specialist Care, Resident #1's treatment, and how inaccurate comments made by the Administrator during the 01/23/2025 care plan meeting. A review of the email dated 02/18/2025 sent to the Facility's Administrator documented that Resident #1's Health Care Proxy submitted an inquiry of the Grievance Procedure. A Grievance/Complaint Form dated 02/18/2025, documented the Interdisciplinary team attempted to contact Resident #1's Health Care Proxy with the outcome of the investigation of Resident #1 that was found wet on 02/12/2025, but they were unavailable. A voice message was left. A review of the Grievance/Incident Form dated 02/22/2025, sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested a written response on the incident dated 02/12/2025 when Resident #1 was left unchanged and all prior incidents. A review of the Amended Grievance/Incident Form dated 02/22/2025, sent via email to the Administrator documented Resident #1's Health Care Proxy requested a written response on their grievance dated 02/21/ 2025. A review of the email dated 02/27/2025, sent to the Facility's Administrator documented Resident #1's Health Care Proxy requested the facility's grievance and incident procedures in writing. Resident #1's Health Care Proxy also requested copies of all grievance incidents decisions from 03/11/2024 to present to be sent via regular mail, ensuring the correct address is used. There was no documented evidence that Resident #1's Health Care Proxy requested to review Grievances results prior to mailing. During a telephone interview on 02/20/2025 at 12:52 PM, the Director of Social Service was the grievance officer and responsible for investigating grievances. The Director of Social Service stated they have five business days to investigate the grievance, and they will then notify the complainant verbally over the phone or in person. The Director of Social Service stated they provided verbal outcome of the grievance and did not provide the written results. During a telephone interview on 03/10/2025 at 12:50 PM, Resident #1's Health Care Proxy stated they requested verbal and written response to filed grievances but did not receive any written response to their grievances. During a telephone interview on 03/21/2025 at 1:45 PM, the Facility's Administrator stated the Director of Social Service is responsible for the Grievance process in the facility. The Facility 's Administrator stated the Social Service and Interdisciplinary Team was responsible for providing the results and / or resolution of the grievances to residents or their representatives. The Facility's Administrator further stated residents, or their representatives are entitled to receive a copy of the Grievance intake and a summary of the investigation. The Facility's Administrator stated they received a request from Resident #1's Health Care Proxy for a copy of the grievances and to review them in person. The Facility Administrator stated they set up meetings on 03/12/2025, but Resident #1's healthcare Proxy did not show up despite confirmation of attendance. The Facility's Administrator stated another meeting was set up on 03/18/2025 at 11:00 AM, but Resident #1's Health Care Proxy came later at 11:45 AM and asked if they could review the Grievance copies on another meeting, but no date or time was provided. The Facility's Administrator stated that copies of the grievances were not mailed to Resident #1's Health Care Proxy because they requested that they are reviewed in person. 10 NYCRR 415. 3(d)(1)(ii)

Plan of Correction: ApprovedApril 11, 2025

I. Immediate Corrections Grievances provided Resident #1's Emergency Contact. Written documentation was provided per request, and the concerns were addressed in alignment with the facility's Grievances Policy. Follow-up communications were also conducted to ensure the complainant was informed of the outcome and resolution. II. Identification of Other Residents A full-house grievance audit was conducted. This review confirmed that all grievances submitted during the specified period were fully investigated, resolved, and appropriately closed out. Interviews with residents and/or their emergency contacts confirmed satisfaction with the resolutions. Documentation was provided to those who requested it, demonstrating transparency and adherence to grievance protocol. III. Systemic Changes The Facility Grievance Policy was reviewed, and no revisions were necessary. Upon review, it was determined that the policy remains comprehensive, current, and in full compliance with 42 CFR 483. 10(j). Nevertheless, as a proactive measure, all facility Social Workers were re-educated on the policy to reinforce expectations regarding grievance documentation, resolution timelines, and communication with residents and families. IV. QA Monitoring The Director of Social Work or designee will conduct a weekly audit for 4 weeks then a monthly audit for an additional two months to ensure that all grievances are completed in the appropriate time frame and if a copy of the grievance is requested it will be provided. Audit results will be presented to the QAPI committee during the quarterly meetings. The QAPI committee will review the findings and determine if any further corrective action or policy enhancement is warranted. Person Responsible: Director of Social Services