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F0585
F

Failure to Provide Anonymous Grievance Process and Notification

Terrell, Texas Survey Completed on 08-15-2025

Penalty

Fine: $36,060
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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 notify residents or their representatives on how to file a grievance or complaint in an anonymous manner. During a confidential Resident Council interview with six residents, it was revealed that the residents were unaware of the location of grievance forms and did not know how to file a grievance anonymously. Observations of the facility's common areas confirmed that there were no grievance forms or containers available for submitting grievances. The Activities Director stated that she was the primary person with access to grievance forms and was unsure where else residents could obtain them. If the Activities Director was unavailable, residents could turn in forms to the head nurse, but there was no clear process for anonymous submission. Further interviews with the DON indicated that grievances were filled out in the electronic medical record (EMR), and the Activities Director distributed and assisted with the forms, which were then given to unspecified staff for entry into the EMR. The DON was not aware of who the designated Grievance Official was or the specific process for submitting grievances. Review of the facility's grievance policy showed that residents should be notified on how to file grievances orally, in writing, or anonymously, with postings in prominent locations, but these procedures were not being followed.

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