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F0585
E

Failure to Communicate Grievance Resolutions to Resident

Portland, Oregon Survey Completed on 08-08-2025

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 provide a written grievance resolution or communicate the outcome of a grievance to a resident or the resident's representative regarding missing personal property. According to the facility's policy, grievances are to be documented and resolved within five working days, with outcomes communicated to the resident. Record review showed that a resident with diagnoses of depression and anxiety, who was cognitively intact, reported multiple missing items and stated that staff were aware of the concerns but did not inform the resident about any investigation or resolution. A review of the grievance binder revealed four grievances submitted by the resident, none of which included documented resolutions, signatures, or evidence that the resident was notified of the investigation results. The Social Services Director confirmed responsibility for grievance follow-up but acknowledged the forms were incomplete and could not provide evidence of resident notification. The Administrator also confirmed that the grievance process was not followed, and forms were not completed as required.

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