Resident B reported the lost flip phone to a certified nursing assistant a couple months before federal inspectors arrived in October. The cognitively intact resident, who has weakness on one side of her body from a stroke, enjoyed talking with family on the phone according to her care plan.
But the assistant never filed a grievance form. The Social Service Director couldn't remember being told about the missing phone. And Resident B had to walk to the nurse's station whenever she wanted to make or receive calls.
"The resident had told nursing staff about the lost phone, but no one had ever followed up with her about it," inspectors wrote after interviewing Resident B on October 14.
The breakdown occurred despite clear facility policy requiring staff to document and forward all resident complaints to the grievance official "as soon as practicable." The policy states that "the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form" and forward it to the grievance official.
Certified Nursing Assistant 2 told inspectors she knew Resident B had used the flip phone regularly before it disappeared. When the resident told her the phone was missing, the assistant said she mentioned it to the Social Service Director but never filled out the required paperwork.
"CNA 2 indicated she had not filed a grievance form for Resident B, but she told the Social Service Director about the missing cell phone," the inspection report states.
The Social Service Director, who serves as the facility's grievance official, had no memory of the conversation. During her interview with inspectors, she said "she could not remember if CNA 2 had told them about Resident B having a missing phone."
No grievance form was ever completed. No investigation was launched. The resident's property simply vanished without any official response from the facility.
The missing phone left Resident B dependent on the nursing home's landline system. Instead of being able to call family from the privacy of her room, she had to make trips to the nurse's station whenever she wanted to speak with relatives.
Resident B's care plan, updated in November 2024, specifically noted that she "enjoyed activities such as talking with her family on the phone." The lost device cut off this important connection to the outside world.
Federal nursing home regulations require facilities to honor residents' rights to voice grievances without fear of retaliation. The rules also mandate that facilities establish grievance policies and make prompt efforts to resolve complaints.
The Willows policy manual spells out exactly how staff should handle resident concerns. Grievances can be voiced as "verbal complaint to a staff member," and the employee receiving the complaint must document it on the designated form and forward it to the grievance official.
The policy also requires the grievance official to "keep the resident appropriately apprised of progress towards resolution of the grievances."
None of this happened for Resident B.
The Social Service Director explained to inspectors that whoever receives a grievance "needed to fill out a grievance form and then it would be given to herself or placed under her door (if she was gone) to follow up on." But the system failed when the nursing assistant didn't complete the required documentation.
The violation represents more than just missing paperwork. Personal items like cell phones provide residents with independence and connection to family members. When these items disappear, facilities are supposed to investigate and try to recover them.
Instead, Resident B's complaint disappeared into the communication gap between a nursing assistant who thought telling her supervisor was sufficient and a Social Service Director who couldn't recall the conversation.
The inspection found the facility failed to ensure grievances were properly forwarded to the grievance official for resolution. Federal inspectors cited Willows of Richmond for violating residents' rights to voice complaints and receive appropriate responses.
Months after reporting her missing phone, Resident B was still making trips to the nurse's station when she wanted to hear her family's voices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willows of Richmond from 2025-10-15 including all violations, facility responses, and corrective action plans.