F0585

D

Failure to Inform Resident of Grievance Investigation Findings and Actions

Glendale, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The facility failed to honor a resident’s right to be informed in writing of the findings and corrective actions related to multiple grievances, as required by its grievance policy. The resident, who had intact cognitive function and no documented behavioral symptoms, had been admitted with conditions including post-surgical amputation, acute osteomyelitis of the right ankle and foot, and diabetes mellitus. Review of nine Grievance/Complaint/Theft and Loss (GCT) forms filed by this resident over several months showed documentation of the grievance, investigation, recommended corrective action, and resolution, but did not include the investigation findings, the date or documentation that the resident was informed of those findings, or the corrective actions that would be taken. The forms also lacked a date indicating when the resident signed in acknowledgment of resolution.

During interview, the resident reported signing the GCT forms when the former Social Service Director initially presented them but stated he was never informed of the investigation findings or actions taken. The DON’s review of the GCT forms, Social Service Progress Notes, and the medical record confirmed there was no documentation that the resident was informed of the investigation findings or corrective actions. The DON stated that the resident had signed the form at the time of filing the grievance, but in the section designated for resolution, and that no follow-up actions were relayed to the resident regarding the filed grievances. The facility’s written policy required that the resident or representative be informed of the investigation findings and corrective actions, both orally and in writing, and that a written summary be provided to the resident and filed in the Social Service office, which did not occur in this case.