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F0585
D

Failure to Promptly Address and Resolve Resident Grievance

Baltimore, Maryland Survey Completed on 09-18-2025

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

Facility staff failed to make prompt efforts to resolve a grievance and did not keep the resident's representative informed of progress toward resolution. A resident, who had been determined by two physicians to lack mental capacity, had their children acting as surrogate decision makers. On the evening in question, one of the resident's children expressed concern about the resident's deteriorating condition and requested that an LPN call an ambulance. The LPN refused, instructed the family to call themselves, argued with the family, and did not check on the resident after the request. The family sent an email complaint to facility management and the Social Work Director that night, but received no response. Review of the facility's grievance logs showed no record of this complaint, and the Administrator initially denied knowledge of any grievance related to the resident. Upon further inquiry, it was revealed that the Social Work Director had forwarded the family's email to the Administrator, who confirmed receipt but did not initiate the grievance process or follow up with the resident's representative. The Administrator stated that no action was taken because the resident had been discharged, despite being the designated Grievance Officer for the facility.

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