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F0585
D

Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Money

Savoy, Texas Survey Completed on 05-29-2025

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 ensure prompt efforts were made to resolve a grievance for one resident who reported missing $250 from her room. The resident, who was cognitively intact and able to communicate her needs, informed the Administrator about the missing money. Despite this report, no grievance form was filed, and the resident was not appropriately apprised of the progress toward a resolution. The facility's grievance log did not contain any entry for this incident, and staff interviews confirmed that the required grievance process was not followed. The resident had a history of making negative statements and allegations, but the facility's policy required that all grievances be documented and investigated. The Social Worker and DON both acknowledged that a grievance form should have been completed, and the Administrator admitted that the usual process was not followed in this case. The failure to document and address the grievance as per policy meant that other staff were not made aware of the incident, and there was no formal record of the steps taken to resolve the resident's concern.

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