Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
of F585 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025695
Every F585 citation surveyors wrote nationally that year.
Facilities cited671
Distinct nursing homes with at least one F585 finding.
The harm level
How severely F585 is cited
0.2% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J10.0%
K10.0%
L—
Actual harm
G30.1%
H—
I—
No harm, potential for more than minimal
D1,66363.4%
E74728.5%
F1415.4%
No harm, potential for minimal
A—
B301.1%
C391.5%
Every recorded F585 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F585 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternMarch 27, 2024
Based on record review and Resident, Resident Representative (RR) and staff interviews the facility failed to implement grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 the facility was running out of her Methadone. The Director of Nursing (DON) was assigned the grievance and on 12/01/23 confirmed Resident #21 had Methadone in the medication cart, and it had been documented as administered. The DON did not interview the resident or determine if there had been any supply issues with Resident #21's Methadone. Due to the lack of investigation this problem continued. Resident #21 reported she experienced terrible/awful pain of greater than ten on a scale of 1 to 10. …
Based on record review and interview, the facility failed to ensure grievances were received and tracked by an identified grievance official per facility policy. The ADON identified 76 residents resided at the facility.Findings: Facility's grievance binder was reviewed. The binder contained several grievances filed by Resident #23 dated 01/07/26 and 03/19/26. The grievance dated 01/07/26 had no investigation reports attached.An undated policy titled, Grievance policy and procedure, read in part, the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and actions that will be taken to correct any identified problems.On 03/24/26 at 9:30 a.m., Resident #23 stated that they had filled out multiple grievances… …
D · No harm, potential for more than minimal, isolatedSeptember 16, 2026
Based on interview and document review, the facility failed to investigate, document, and track resolution of a resident grievance regarding resident (R13) entering their room and going through their belongings for 6 of 6 resident (R4, R10, R11, R15, R24, R25) reviewed for grievances.Findings include:R13R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and diagnoses that included Alzheimer's disease and dementia. R13 exhibited wandering daily. R13 used a bed alarm and a wander/elopement alarm.R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/21/25, identified R13 had dual dx of Alzheimer's disease and dementia. …
C · No harm, potential for minimal, widespreadAugust 24, 2026
Based on observation, interview, and record review, the facility failed to maintain evidence of grievance decisions for a period of no less than 3 years from the date of the grievance decision. This placed residents at risk for grievances not being resolved or documented. Findings include:On 8/17/26, an Entrance Conference letter request for grievances related to call lights, activities of daily living (ADLs), resident rights, and resident safety from 3/1/26 through 5/10/26 was submitted to Staff 1 (Administrator). On 8/17/26 at 11:15 AM, Staff 1 reported the 2026 grievance binder could not be located and was unavailable for review. On 8/21/26 at 10:00 AM, Staff 1 reported the grievance binder was last seen approximately two weeks earlier. …
Cited in the same inspection, not caused by one another.
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