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F0585
D

Failure to Establish Timely Grievance Resolution Process

Ashland, Oregon Survey Completed on 05-09-2025

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 maintain a grievance policy that included a reasonable timeframe for reviewing and resolving grievances, as evidenced by the handling of a grievance submitted on behalf of a resident with respiratory failure and chronic pain. The resident, who was cognitively intact and required assistance with eating, had a physician order for continuous oxygen. A family member submitted a grievance regarding concerns about the resident's oxygen, meal assistance, pressure ulcer interventions, and missing items. The care plan was reviewed and updated, and a meeting was scheduled, but there was no documented communication of findings or updates to the complainant until the scheduled meeting. Staff interviews revealed that the Director of Nursing spoke with a registered nurse about the oxygen issue, but this was not documented in the medical record, nor was the complainant informed of any findings prior to the meeting. The grievance officer only spoke with the complainant at the scheduled meeting, and the facility's policy did not specify a formalized timeline for grievance resolution. The regional nurse expected a response to the complainant within five days, but the facility's process did not ensure timely communication or resolution, and the policy required revision to address these deficiencies.

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