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F0553
D

Failure to Honor Resident's Request for Care Plan Meeting with Ombudsman

Galesburg, Illinois Survey Completed on 08-19-2025

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 honor a cognitively intact resident's request to participate in a care plan meeting with the ombudsman present. The resident had submitted a grievance regarding inconsistent bathing and hair care after a change in CNA assignments and specifically requested a care plan meeting with the ombudsman to discuss these concerns. Despite the resident's repeated verbal and written requests, and the ombudsman's direct communication with the prior administrator and DON about scheduling the meeting, no care plan meeting was arranged or documented in the resident's electronic health record during the review period. Interviews confirmed that the resident continued to express frustration about not being heard and not having the requested meeting, and the ombudsman reported never receiving follow-up from facility leadership after the initial discussion. The Social Service Director, responsible for scheduling care plan meetings, stated they were never informed of the resident's request. At the time of observation, the resident's hair appeared oily and stringy, and the resident expressed ongoing dissatisfaction with care and communication from staff.

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