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F0585
D

Failure to File and Resolve Resident Grievance Regarding Missing Personal Items

Bonham, Texas Survey Completed on 07-23-2025

Penalty

No penalty information released
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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 honor a resident's right to voice grievances and did not make prompt efforts to resolve a grievance regarding missing personal clothing. A female resident with Alzheimer's disease, but with intact cognition and the ability to communicate her needs, reported missing green pants, white capri pants, and a bright colored blouse to the Housekeeping Supervisor. The resident stated that her items had been missing for several weeks and she had not received any updates on whether the items were found or would be replaced, leading to her frustration. Review of facility records confirmed that no grievance was filed for the missing clothing during the relevant period. The Housekeeping Supervisor acknowledged receiving the report about the missing green pants but did not conduct a full search or report the issue to the Administrator as required by facility policy. The Administrator confirmed that she had not received a grievance regarding the missing clothing and stated that her expectation was for such incidents to be reported so a grievance could be filed and tracked. The facility's grievance policy specifies that the Administrator or designee is responsible for receiving and tracking grievances to their conclusion, but this process was not followed in this instance.

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