F0585

D

Failure to Document and Address Resident Grievances About Care and Assistance

Los Angeles, California Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly address and document a cognitively intact resident’s repeated grievances about inadequate assistance and nursing care. The resident was admitted with esophagitis, duodenal ulcer, and generalized muscle weakness, and assessments showed he used a walker and wheelchair, was independent with several ADLs, and required assistance with toileting hygiene and bathing. A later history and physical documented that the resident had capacity to make medical decisions and had expressed dissatisfaction with staff and the facility, specifically reporting inadequate assistance and communication issues. During an interview conducted with a translation hotline, the resident reported ongoing diarrhea, stated he did not understand why his medications were not working, and complained that CNAs, housekeeping, and licensed nurses were not providing the assistance he needed.

Staff interviews confirmed that the resident voiced many complaints about charge nurses, housekeeping, and CNAs, and that he repeated these complaints. The ADON reported that the last IDT meeting with the resident, used to discuss the plan of care and any concerns, occurred on 11/11/25, despite the resident’s ongoing complaints. The social worker stated that no grievance had been filed for this resident and that his multiple complaints were addressed immediately, but the facility could not provide any documentation to support that the complaints were recorded or resolved. This was inconsistent with the facility’s written grievance policy, which requires staff to record the nature and specifics of grievances on a designated form, for the grievance official to log and document actions taken, and to keep the resident informed of progress toward resolution.