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F0585
D

Failure to Investigate and Address Resident Grievance Regarding Pest Infestation

Los Angeles, California Survey Completed on 12-15-2025

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 promptly address and investigate grievances reported by a resident who was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures. The resident, who was cognitively intact and able to communicate clearly, reported seeing cockroaches in her bathroom on several occasions shortly after admission. Despite making multiple complaints to facility staff, her concerns were not addressed, and no grievance form was initiated as required by facility policy. Interviews with staff, including a registered nurse, the Social Services Director, and the Director of Nursing, confirmed that the resident's complaints were not documented or investigated according to the facility's grievance procedures. The facility's grievance log did not show any record of the resident's concern, and staff acknowledged that the grievance process should have been initiated to ensure the resident's concerns were properly addressed. The failure to follow the established grievance policy resulted in the resident's right to voice grievances without discrimination or reprisal not being honored.

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