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F0585
D

Failure to Provide Accessible and Anonymous Grievance Submission

Haverford, Pennsylvania Survey Completed on 06-12-2025

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 residents and their representatives could file grievances or concerns anonymously, as required by their own grievance policy. The policy stated that grievance forms were available in several public areas and that completed forms could be anonymously delivered to an out-going box outside the Activities Room on the second floor. However, observations revealed that there were no grievance boxes present in the public areas of either the first or second floors, including outside the Activities Room. Instead, the only available out-going wall basket was located outside the social worker's office, mounted at a height inaccessible to residents in wheelchairs and lacking any identifying label. Interviews with staff confirmed the absence of grievance boxes in the designated areas, and the social worker reported that she typically completed grievance forms on behalf of residents. Additionally, interviews with five randomly selected residents revealed that most were unaware of the location of the grievance box, with only one resident recalling that the information was provided upon admission. These findings demonstrate that the facility did not provide residents and their representatives with a clear, accessible, and anonymous method to submit grievances, as outlined in their policy.

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