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F0585
D

Failure to Investigate and Document Resident Grievance

Newhall, California Survey Completed on 08-12-2025

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 resident with multiple sclerosis, schizophrenia, and bipolar disorder, who was assessed as having intact cognitive skills and the capacity to make decisions, reported an incident in which another resident touched his legs, causing him to feel scared and uncomfortable due to existing wounds in the area. The resident communicated this concern to an LVN, who then relayed the complaint to the Social Services Assistant (SSA). However, the SSA did not ask the resident about the complaint during their interaction and did not document the concern. A review of the facility's grievance policy indicated that all grievances and complaints must be investigated and documented, including the resident's account of the incident. The Director of Nursing confirmed that the complaint was not verified or investigated, and there was no documentation of the incident as required by policy. This failure to investigate and document the resident's grievance constituted a violation of the facility's procedures for addressing resident complaints.

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