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F0585
D

Inaccessible Grievance Forms and Box on Fourth Floor

Pittsburgh, Pennsylvania Survey Completed on 02-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide and make accessible grievance forms and a grievance box to residents and visitors on the fourth-floor nursing unit. During an observation, it was noted that a trash bin was placed in front of the grievance box, obstructing access. Additionally, grievance forms were not present on the fourth-floor nursing unit, which is a requirement for residents to voice their grievances effectively. The Director of Nursing confirmed these findings during an interview, acknowledging the facility's failure to comply with the requirement to make grievance forms and the grievance box accessible. This deficiency was identified based on a review of the facility's policy and observations made during the survey.

Plan Of Correction

No residents were affected by not having the forms and box accessible due to the trash in front of the box and no forms present. This does present a potential and the Grievance Officer was educated on the Grievance policy by the NHA and or designee. Trash bins removed and forms added. Grievance officer or designee will audit forms being present and no obstructions 3 times a week for 4 weeks in identified locations. Results will be reported to the quality improvement and process improvement.

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