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F0585
D

Failure to Promptly Resolve and Communicate Resident Grievance

Carrollton, Texas Survey Completed on 12-10-2025

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 a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a cognitively intact male resident with a history of anxiety, depression, diabetes, morbid obesity, and multiple sclerosis submitted a grievance regarding an undercooked baked potato served at dinner. The resident reported that after submitting the grievance form to the Assistant Director of Nursing (ADM), the Dietary Manager (DM) approached him but did not apologize or take responsibility for the issue. Instead, the DM asked if the resident had requested the dietary staff to reheat the potato and suggested that he should notify staff immediately if such issues occur again. The resident felt that his concerns were not properly addressed and that there was no direct follow-up regarding the status of his grievance. Further review revealed that the facility's grievance policy required prompt resolution and a written response to the resident, including details of the investigation and outcome. However, neither the DM nor the ADM provided the resident with a written resolution or communicated the outcome of the grievance. The ADM confirmed that the grievance form was handed to the DM for follow-up, but no resolution was documented or conveyed to the resident as required by policy. This lack of appropriate response and communication constituted a failure to resolve the resident's grievance in accordance with facility policy.

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