F0585

E

Failure to Inform Residents of Grievance Process and Provide Accessible Grievance Forms

Denison, Texas Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The facility failed to ensure residents were informed on how to file a grievance or complaint and were not made aware of the facility’s grievance policy, as required by its own policy and resident rights regulations. In a confidential group interview with six residents, all residents reported they did not know how to file a grievance and were unaware of who to approach with individual grievances. All six residents stated they wanted the ability to write down their grievances themselves and submit them to the facility, but reported the facility had not informed them of its grievance policy. Three of the six residents reported there was a binder labeled “grievance” in the resident activity room, but that it did not contain grievance forms.

Observation of the grievance binder in the resident activity room showed it contained only blank coloring pages and no grievance forms or information on grievances. The DON stated residents could report grievances to any staff member, who would then enter the grievance into a computerized system, and confirmed there was no specific grievance form available for residents to complete on their own. The Activity Director, who attended resident council meetings, stated she had not discussed grievances or the grievance policy with residents, was unaware of the specific grievance policy, and identified the Administrator as responsible for grievances. The Administrator confirmed she was responsible for overseeing grievances and the grievance policy, stated residents could report grievances orally to staff who would write them down, and acknowledged there was no form available for residents to independently submit written grievances, despite the facility’s policy stating information on how to file a grievance or complaint must be made available to the patient.