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F0585
E

Failure to Provide Access and Information on Grievance Procedures

Big Spring, Texas Survey Completed on 06-12-2025

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 provide residents and their representatives with information regarding their rights to file grievances, including the process for submitting grievances anonymously. During a Resident Council meeting, 12 out of 22 residents reported they did not have access to grievance forms, were unaware of the option to file grievances anonymously, and did not know where or how to submit an anonymous grievance. These residents, all of whom had resided in the facility for over six months, stated that grievance forms were only available by requesting them from the Activities Director (AD), and that the AD typically completed the forms during council meetings when complaints were voiced. The grievance procedure had not been discussed in Resident Council meetings. A review of the facility's grievance policy confirmed that anonymous grievances could be submitted in a locked box on hall 3. However, surveyor observation revealed that the box was labeled for payments and not for grievances, and grievance forms were not available in the hallways. The Director of Nursing (DON), who served as the Grievance Officer, stated that grievance forms were kept in her office and with the AD, and that staff typically completed the forms for residents. The DON also acknowledged there was no established procedure for residents to submit grievances anonymously and was unaware that the grievance process was not being discussed in Resident Council meetings.

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