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F0585
D

Resident Discouraged from Filing Grievances Without Fear of Reprisal

Broken Arrow, Oklahoma Survey Completed on 07-08-2025

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

The facility failed to ensure that a resident was able to file grievances without fear of reprisal. A resident with intact cognition and multiple medical diagnoses, including hypertension, renal insufficiency, and diabetes, submitted grievances regarding issues with another resident and concerns about unsupervised children in the facility. Documentation showed that after submitting these grievances, the resident was approached by the social services director (SSD) and activities director (AD), who questioned the resident about their satisfaction with living at the facility and suggested that if they were unhappy, they might consider whether the facility was the right place for them. During this conversation, the resident became visibly upset and expressed feeling silenced, stating they would "just shut [their] mouth and not say a word ever again." Further evidence from a video recording and interviews confirmed that the resident was told to be careful about how much they complained about matters not in their control, and that repeated complaints could result in consideration of alternative placement. The resident reported feeling threatened and stated that the interaction had taken away their joy of being around people. Staff interviews revealed conflicting perspectives, with the SSD acknowledging that telling a resident to be careful about complaining would be inappropriate, while the AD stated that residents could submit as many grievances as they wished. The facility's grievance policy was described as allowing residents to submit grievances without limitation, but the actions taken in this case did not align with that policy.

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