Health inspection·August 30, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews, and record review, the facility failed to notify residents on how to file a grievance in an anonymous manner, and the contact information of the Grievance Official for 4 confidential residents out of 4 residents interviewed for grievances. 1.The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2.The facility failed to communicate to the residents who the facility identified as the Grievance Official. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance.Observation on 08/30/2025 at 3:31 PM of a sign posted on a wall near the activities room titled, Social Services Policies and Procedures Complaints/Grievances Process revealed: Grievances/Complaints are accepted by the following, but not limited to:A. AdministratorB. Department manager or his/her designeeC. SupervisorD. Unit manager3. The receiver of the grievance/complaint instructs the complainant to complete appropriate sections of the Complaint/Grievance Report. If the complainant is unable to complete these sections, the social worker/designee is contacted to provide assistance m documenting the grievance/complaint issue.There were no blank grievance forms observed near the posting or anywhere in the facility where residents or their representatives could obtain a grievance form and/or turn in grievance forms anonymously. A Grievance Official and their contact information was also not indicated on the posting. In confidential interviews on 08/30/2025 between 2:00 PM - 3:45 PM with four residents who were members of and not members of Resident Counsel revealed that the residents did not know how to file grievances anonymously due to having to obtain grievance forms from department heads and the forms were in those respective staff offices. They stated there was not a place to obtain blank grievance forms by themselves or during weekends/holidays when department heads may not be available. The residents stated that they did not know they had the right to file grievances/complaints anonymously, or who the designated grievance official was. They also stated that if they had a grievance about a specific staff member, they would not want to have to turn the grievance into that person but would rather there be a way to discreetly turn it in so that the staff member would not know about it. In an interview on 08/30/2025 at 2:15 PM with the AD she stated she had worked at the facility for 3 years, and that residents were to file grievances with the ADM. She stated that if a resident came to her wanting to file a grievance, she would go get a grievance form from the ADM, fill it out, then give it back to the ADM. She stated she was not aware of a grievance box or a place in the facility where residents could turn in anonymous grievances. She stated the staff would slip the completed grievance form under the ADM's door if he was not at the facility. She stated during resident council, they would read off resident rights before the start of the meetings. She stated she had never thought of how a resident could fill out a grievance privately if it all went through the Page 1 of 2 676197 676197 08/30/2025 Ridgeview Rehabilitation and Skilled Nursing 206 Walls Dr Cleburne, TX 76033

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADM. In an interview on 08/30/2025 at 2:20 PM with the SW, she stated that sometimes residents would go to her to make a grievance, where she would write it out for them. She stated residents must physically obtain the form from her and she would help them fill it out. She stated that residents could slip the completed grievance forms under her door if they chose to fill it out themselves, and that there was no box for residents to access for anonymous grievances. She said that if a grievance was turned into her, she would give it to the appropriate department head and the yellow copy (attached to the back) was turned into the ADM. In an interview on 08/30/2025 with the DON and ADM at 2:25 PM when asked where residents could obtain grievance forms from, they stated that the residents could ask any department head for a grievance form, or they could ask the resident council president who would obtain the form on behalf of the resident requesting one. They stated that all managers had the forms in their offices. They stated that they have never had a discreet place for the residents to obtain grievance forms from or turn them into, and the grievances had to be turned into a department head. The DON stated that the ADM was the grievance official.Review of the facility's policy titled; Grievances/Notification of Grievance Policies/Grievance Procedures dated September 2024 revealed that: 3. The facility will notify patients and their representative orally or through postings around the facility in prominent locations on; B. Who the facility grievance official is and their contact information.D. Their right to file a grievance in an anonymous mannerE. How to file an anonymous grievanceReview of the facility's policy titled; Resident Rights dated December 2016 revealed that: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:t. privacy and confidentialityu. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; 676197 Page 2 of 2