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F0565
D

Failure to Document and Resolve Resident Grievances

Delray Beach, Florida Survey Completed on 06-16-2025

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 appropriately respond to and resolve grievances for one resident, as required by its own grievance policy. The policy states that grievances may be voiced verbally to staff and must be documented on the facility grievance report. However, a review of the grievance records for May did not show any documentation of complaints or concerns from the resident's son, despite his statements that he reported multiple issues to both the former and new Administrators. These issues included concerns about medications, falls, a non-functioning bed and TV, and resident rights. The son reported that he did not receive any updates or progress regarding his complaints, and was particularly concerned about medications not being administered until the night before the resident's discharge. The resident involved had multiple diagnoses, including pulmonary hypertension, muscle wasting and atrophy, type 2 diabetes mellitus with peripheral angiopathy, atrial fibrillation, hypothyroidism, and chronic kidney disease. The resident was assessed as having intact mental cognition. Staff interviews revealed that grievances are typically assigned and resolved within a few days, and that maintenance issues are usually addressed promptly. However, the staff member responsible for social services was unable to explain why the resident's grievances were not documented in the report, stating that there were no reported grievances from the resident, despite the son's statements to the contrary.

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