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F0585
D

Failure to Honor Grievance Resolution Regarding Resident Care Assignment

Scappoose, Oregon Survey Completed on 08-26-2025

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 grievance resolution for a resident with dementia and a femur fracture, who had significant cognitive impairments. A grievance was filed by the resident's Power of Attorney (POA) after a CNA forced the POA to leave the resident's room during care and subsequently left the room when the POA requested to stay. The POA requested that this CNA no longer provide care to the resident, and the Director of Nursing Services documented that the resolution was for the CNA to be removed from providing care to this resident. Despite this documented resolution, facility records showed that the CNA continued to provide ADL care, including brief changes, oral hygiene, showers, and vital sign assessments to the resident on multiple occasions after the grievance was resolved. The POA observed the CNA providing care on at least one occasion and reported this to facility staff. The Director of Nursing Services confirmed that records indicated the CNA continued to provide care to the resident after the grievance resolution.

See complete original report
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