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: May 20, 2025

Citation Details

Based on observations, interviews, and record review conducted during the Recertification Survey completed 9/30/22, it was determined that the facility did not post, in a manner accessible and understandable to residents and resident representatives, the pertinent contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline number, including a statement that the resident may file a complaint. The findings are: The Homestead Group Committee Meeting Minutes dated (MONTH) 15, 2022, (MONTH) 12, 2022, and (MONTH) 9, 2022, included that the Ombudsman contact information was provided, that pamphlets were available from Social Work and that posters (with the information) were located at entrances to the facility. During an interview on 9/28/22 at 11:17 a.m., the Resident Council President stated they were not allowed off their units, so they were unable to see the posters with contact information on them. When observed on 9/28/22 at 12:03 p.m., the required postings were not located at the entrance to the building on the ground floor. The State Agency Complaint Hotline number was located in the Administration hallway and the Ombudsman contact information was not located. When interviewed on 9/29/22 at 1:50 p.m., the Administrator stated that the required postings were available in two different parts of the building, the hallway outside of the Administration offices (not a hallway that resident's normally pass through) and outside of the Social Work office between units one and two. The Administrator also stated that the Ombudsman contact information was discussed monthly at the Resident's Council meeting. In an observation on 9/29/22 at 2:03 p.m., the area outside of the Social Work office did not contain any postings of the State Long-Term Care Ombudsman Program or the State Agency Complaint Hotline number. 10NYCRR 415. 3(d)(3)

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