F0585

E

Failure to Investigate and Communicate Resident Grievances as Required

Pomona, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to have those grievances promptly and thoroughly investigated and communicated. Staff interviews showed that some RNs did not guide residents or representatives on how to file written grievances, did not know where grievance forms were located, and did not know who the facility’s Grievance Officer was, despite facility policy requiring staff to provide this information. The facility’s written grievance policies required that all grievances be investigated, that the Grievance Officer initiate investigations, and that complainants be informed verbally and in writing of the findings and corrective actions.

One affected resident, identified as Resident 6, was admitted with type 2 diabetes mellitus, dementia, and anxiety disorder, and required staff assistance with bathing, dressing, toileting, and personal hygiene. Resident 6’s representative submitted a written grievance on 10/16/2025 alleging that the resident’s clothing and bedding had not been changed for a week, that the resident was not being showered, that call lights were not answered timely, that food was not served warm leading to weight loss, that the physician was not visiting, and that a dental appointment had not been arranged. The grievance form’s investigation section only addressed the concerns about showers and changing clothes and linens, and did not document any investigation into the complaints about call light response, food temperature, weight loss, physician visits, or dental arrangements. The Social Services Director reported only leaving a message for the representative and did not speak with the representative about the investigation results, and no written report of findings was provided to the representative.

Another affected resident, identified as Resident 17, had a history of falls, bone density disorder, and osteoarthritis, with moderate cognitive impairment and a need for substantial/maximal assistance with bathing, lower body dressing, and personal and toileting hygiene. This resident filed a grievance on 1/23/2026 stating that they waited two hours for CNA assistance to get into bed after being left in the hallway. The grievance form for this complaint contained no documented investigation report. The resident stated that no one from the facility spoke with them about the grievance after it was filed. The Social Services Director acknowledged not following up with the resident and not providing a written report, and the Director of Staff Development stated they did not investigate the grievance because they were never informed of it. These actions and omissions conflicted with the facility’s grievance policies, which required investigation of all grievances and verbal and written notification of findings to the complainant within five working days.