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F0585
E

Failure to Post Grievance Procedure and Timely Resolve Resident Grievance

Charlottesville, Virginia Survey Completed on 07-24-2025

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

Facility staff failed to resolve a resident grievance in a timely manner, did not post the identification of the grievance officer, and did not display the grievance procedure in the facility. During a tour of multiple nursing units and the lobby, surveyors observed that there was no information posted regarding the grievance officer or the process for filing a grievance. At a resident council meeting attended by 15 residents, none were aware of who the grievance officer was or how to file a grievance. Residents expressed that they were unaware of grievance forms and did not know if a grievance officer existed at the facility. Interviews with staff, including the activity director and social service director, revealed that they also did not know who the grievance officer was. The administrator later stated that they were currently acting as the grievance officer due to staff turnover, and confirmed that there was no posting about the grievance officer or procedure. A review of facility documentation showed that a grievance filed by a resident's responsible person listed five concerns and was not resolved until the resident's discharge, which was nearly three weeks after the grievance was filed. The facility's policy requires that concerns be discussed with the interdisciplinary team the day after receipt and that investigations be completed within 5-7 business days. The delay in resolving the grievance and the lack of posted information about the grievance process and officer were confirmed during the survey, and no additional information was provided by facility leadership prior to the exit interview.

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