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F0585
D

Failure to Document and Address Resident Grievances

Yoakum, Texas Survey Completed on 11-18-2025

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 that residents had the right to voice grievances without discrimination or reprisal, as required by policy. Specifically, a resident's representative made two separate complaints to LVN A regarding the care provided: one about blood observed on the resident's linens, and another about the absence of a bedside table. Despite these grievances being communicated directly to LVN A, no grievance reports were generated for either incident. The resident in question was an elderly male with dementia, admitted for long-term care and requiring substantial assistance with activities of daily living, including care for an indwelling urinary catheter. The representative observed issues through a bedroom camera and contacted the facility to express concerns about possible bleeding related to the catheter and the removal of the bedside table. LVN A acknowledged receiving these complaints and documented some aspects in the nursing progress notes but did not initiate the formal grievance process as outlined in facility policy. Interviews with the facility's Administrator and DON confirmed that staff are expected to assist in generating grievance forms and submitting them for review. However, in these instances, LVN A did not follow the established grievance procedure, resulting in the grievances not being formally addressed or resolved. The facility's policy clearly states that all grievances should be documented and reviewed, but this process was not followed for the resident's representative's complaints.

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