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F0585
D

Failure to Document and Address Resident Grievance

Lawndale, California Survey Completed on 04-08-2025

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 implement its grievance policy and procedure for one resident who reported an issue with her roommate repeatedly touching the privacy curtain, which caused her distress. The resident, who had no cognitive impairment and was able to make her own decisions, stated that she reported the issue to a staff member, but no action was taken. The facility's grievance log did not contain any record of this concern, and there was no documentation of any investigation or follow-up regarding the resident's complaint. Interviews with the Social Services Director and the Director of Nursing confirmed that the grievance should have been documented and addressed according to facility policy, which requires grievances to be logged and investigated with appropriate follow-up. The Social Services Director acknowledged that a room change was offered but declined by the resident, yet this was not documented. The lack of documentation and follow-up meant the resident's grievance was not formally acknowledged or resolved as required by the facility's policy.

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