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F0585
D

Failure to Provide Grievance Education and Accessible Grievance Materials

Lima, Pennsylvania Survey Completed on 07-18-2025

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 evidence that residents were educated on the process of filing grievances and did not ensure that grievance forms or boxes were available and accessible on the nursing units across five floors. Observations on multiple floors revealed the absence of grievance forms and drop boxes, and staff interviews confirmed that these resources were not present. Instead, staff reported that residents could either call a posted phone number, write complaints on plain paper, or use blank envelopes to submit grievances, but no standardized forms or accessible boxes were available on the units. In the main lobby, a complaint box was observed, but no grievance forms were available for residents to use. Review of facility documentation, including resident council minutes, showed no evidence of education or discussion regarding the grievance process. Additionally, the Director of Nursing confirmed that the facility did not have a formal grievance policy in place. The facility's policy on resident rights referenced staff training but did not address resident education or the availability of grievance materials. These findings demonstrate a lack of compliance with requirements to honor residents' rights to voice grievances without discrimination or reprisal.

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