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F0585
D

Failure to Notify Resident Representative of Grievance Resolution

Ottawa, Illinois Survey Completed on 05-08-2025

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

A deficiency occurred when the facility failed to notify a resident's representative of the resolution of a grievance. The resident's daughter and Power of Attorney (POA) arrived at the facility and found the resident in bed, soaked in urine, with a strong urine odor in the room, and the resident had not been gotten up or fed breakfast. The POA communicated her concerns to the Resource Nurse via text and in person, expressing her desire to file a grievance and requesting follow-up. Despite this, the POA reported that she did not receive any communication from the facility regarding the findings or resolution of her grievance for nearly a month. The Resource Nurse confirmed receiving the grievance and acknowledged that an update should have been provided within 24 hours, but no follow-up communication was made to the POA. The Social Service staff completed a grievance form and documented the concern, but also did not notify the POA of the facility's response or findings. The facility's grievance policy requires that the resident or their representative be informed of the investigation's findings and corrective actions within seven working days, which was not done in this case.

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