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F0585
D

Failure to Communicate Grievance Resolution to Resident

Salem, Oregon Survey Completed on 06-06-2025

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 chronic pain and PTSD, who was cognitively intact at admission, reported that nursing staff failed to administer prescribed pain medication in a timely manner. After waiting for an extended period and missing a physical therapy session due to pain, the resident attempted to voice concerns to the Director of Nursing Services (DNS), who responded dismissively and directed the resident to leave her office. The resident described the DNS as rude and disrespectful, and subsequently completed a grievance form with the assistance of staff, which was submitted to the administrator's office. Despite the facility's grievance policy requiring prompt action and communication of grievance resolutions to residents, the resident did not receive any follow-up or written resolution regarding the grievance. Multiple staff members, including the Social Service Director and the Administrator, were unaware of the grievance submission until after the fact. The grievance process was not followed, and the resident's concerns about pain management and staff conduct were not addressed in accordance with facility policy.

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