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F0585
D

Failure to Follow Grievance Policy for Missing Resident Clothing

White Sulphur Spring, West Virginia Survey Completed on 11-19-2025

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 implement its grievance policy and procedure regarding a report of missing clothing for a resident. According to the electronic medical record, a resident's sister reported that she had brought in twelve pairs of socks, which were later found to be missing from the resident's room. Nursing staff checked with laundry, but the socks were not located, and the incident was documented. However, there was no further documentation in the medical record regarding follow-up or resolution of the missing items. Additionally, a review of the facility's grievance log revealed that no written grievance was completed for this incident. Interviews with staff indicated inconsistent understanding and execution of the grievance process. The resident's representative reported not being contacted after initially reporting the missing socks. The social worker stated she was not informed of the missing items, and the administrator acknowledged that there was no evidence of an investigation or follow-up as required by the facility's grievance policy. The policy specifies that concerns should be documented, logged, and followed up with timely communication to the person filing the grievance, none of which occurred in this case.

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