As part of the full inspection process, licensors will complete a full resident record review for each resident in the sample. While the record review is an important part of the inspection process, this step ideally is focused on collecting specific information to validate or clarify issues gathered during observations and interviews. It is important, then, that the provider ensures that the documents in a resident’s record are complete, accurate, and reflect the services offered and provided. 

If the facility’s resident records are in paper format, it is highly recommended to have a system in place whereby outdated documents are archived; this will speed the licensors’ review process and offer easy access for staff when looking for specific documents. If the resident records are housed in an electronic format, be prepared to either share access with the licensors, or print off requested documents in a timely manner.

For each sample resident, the licensors will review the records to ensure the following:

  • For residents who moved in within the last six months, the licensor will ensure that a pre-admission assessment was conducted before the resident moved in, and that the assessment was completed by a qualified assessor. They will also ensure a full assessment was completed within 14 days of moving in.
  • Annual assessments completed. For residents receiving services on a Specialized Dementia Care Medicaid contract, the full assessment must be done every six months.
  • Limited change of condition assessment is documented as needed.

  • The assisted living has a system in place to capture changed in a resident’s condition; these changes are documented, and appropriate action is taken. These might come in the form of:
  • Incident reports and/or investigations
  • STOP and WATCH or other early change-in-condition detection formats
  • Progress notes
  • Faxes or electronic messaging to health care providers
  • Hospital and clinic records

  • For residents who moved in within the last six months, an initial service plan was in effect upon move-in and completed within 30 days.
  • Updates are made to the NSA as needed.
  • Contents meet the resident’s needs and preferences and include:
  • Defined roles/responsibilities of the resident, staff, outside agencies, and resident’s family; alternate plans are in place when necessary.
  • Approximate times and frequencies services are to be delivered
  • Resident’s preferences for activities, and how/if those are supported.
  • Resident arranged services and/or external health care providers are included, if applicable.

  • If the family participates in any way with medication management – that includes ordering, obtaining, and/or delivering medications, setting up medication organizers, and/or assisting/administering medications – the facility must have a family plan and an alternate plan, complete with directions, responsible party’s name and contact information, and signatures.
  • Facility medication records for sample residents, including any prescribed medication orders, delegation documents and medication assistance/administration records (MARs). Complete documentation in MARs include medications taken, refused (with appropriate follow-up as needed), as-needed medications taken with appropriate follow-up.

The licensors may look at other residents’ records as well, likely on a limited focus based on interviews and/or observations. Should concerns arise from sample residents’ records, licensors may review other residents’ records to determine systemic breakdowns.

The licensing team may look at a closed resident record; this typically occurs when there are concerns about transfer/discharge, or an issue comes up during the inspection that warrants closer scrutiny into the discharged resident’s care and service at the facility.

Facility records are also part of the full licensing inspection. Reviewing facility-specific records may be required to complete data collection regarding a specific issue. These documents include:
  • Incident/accident documentation including details, notification of relevant parties, investigation, and relevant prevention measures.
  • Policies and procedures
  • Financial records. These are rarely reviewed but may be looked at in the event care and services are not being met, or a specific complaint focuses on this topic
  • Quality assurance committee notes (only to determine the existence of a QA committee and that it is operating in compliance with the regulations)

If you have questions about the inspection process in assisted living facilities, please contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
Outlined in section CFR 483.10 Resident Rights in the Federal Register/Vol.81, No.192 are the requirements for all skilled nursing facilities related to management of grievances/complaints. While F585 (Appendix PP - November 22, 2017 ( goes into greater detail regarding the facility responsibility for managing grievances, some key highlights are outlined below:
  • The facility must make information available to the resident on how to file a grievance or complaint.
  • The facility must establish a grievance policy to ensure prompt resolution of all grievances regarding resident rights contained in the rule.
  • The facility must supply a copy of the policy to a resident upon request.
  • The policy must include the information outlined in the rule. This includes identifying a Grievance Official who is responsible for overseeing the grievance process.

All written grievance decisions must include the following:
  • The date the grievance was received,
  • Steps taken to investigate,
  • A summary of pertinent findings or conclusions,
  • A statement of whether the grievance was confirmed or not confirmed,
  • Any corrective action taken or to be taken by the facility, and
  • The date the written decision was issued.
In addition, the facility must maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the date of issuance of the grievance decision.

CMS further explains in the purpose of requiring the facility to have a Grievance Official is to ensure an individual who has both the responsibility and authority, through direct action or coordination with others, that grievances are appropriately managed and resolved. This person is to be a resource for residents, staff, and oversight entities such as RCS. CMS has stated, “It is not our expectation that every facility hires a new, full-time individual to perform this function, but, instead, that every facility has a designated individual to serve this function, consistent with the needs of that facility.”

The state of Washington requirements related to grievances are covered in both the Revised Code of Washington (RCW) and the Washington Administrative Code (WAC). RCW chapter 70.129.060 reinforces a resident’s right to voice grievances and further states that such grievances include those with respect to treatment that has been furnished as well as that which has not been furnished. The statute requires that the facility ensure prompt efforts to resolve grievances the resident may have, including those with respect to the behavior of other residents.

WAC chapter 388-97-0460 echoes the RCW above and reinforces the resident’s right to file a complaint or to contact or provide information to the department, the long-term care ombuds, the attorney general's office, and law enforcement agencies without interference, discrimination, or reprisal. The resident also has the right to receive information from agencies acting as client advocates and be afforded the opportunity to contact these agencies.

A facility needs to actively and proactively manage their grievance program by ensuring all staff are trained and understand their responsibilities related to grievances/complaints. Staff must also have a clear understanding of what constitutes potential abuse, neglect, and exploitation in order to distinguish an allegation that needs to be managed differently than a grievance. By empowering and training all staff, including maintenance, housekeepers, dietary, and direct caregivers, a facility can operationalize a grievance response team in support of the Grievance Official and facility policies that ensures compliance with both the CMS and state requirements.

If you have questions, please email Elena Madrid or call her at (800) 562-6170, extension 105. 
303 Cleveland Avenue SE, Suite 206 | Tumwater, Washington 98501
Tel (800) 562-6170