F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances,
for one (Resident #1) of 6 residents reviewed for grievance resolution.
The facility did not issue a written decision to Resident #1 who filed a grievance.
This failure could place residents at risk for feeling that their voices were not being heard or taken seriously
and could cause feelings of worthlessness.
Findings included:
Record Review of Resident #1's face sheet, dated July 24, 2024, revealed an [AGE] year-old male admitted
to the facility on [DATE] with diagnoses that included but not limited to, Cellulitis (bacterial infection of the
skin) of the left lower limb, diabetes mellitus (high blood sugar), chronic kidney disease, and acquired
absence of left leg below knee.
Record Review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of
14 out of 15 which indicated Resident #1 was cognitively intact.
Record Review of Resident #1's care plan dated 01/13/2024 revealed the following:
Focus: The resident was a risk for falls.
Intervention: Be sure the resident's call light was within reach and encourage the resident to use it for
assistance as needed.
Focus: The resident has a diet order; Regular diet.
Intervention: Determine food preference and provide within dietary limitations.
Record Review of Resident #1's Grievance dated 07/11/2024 revealed the resident's representative filed a
grievance with the facility that included but not limited to food preference and call light times. The resolution
date for the grievance was 07/16/2024 and documentation revealed that the resident was verbally informed
of the grievance by the ADM, but no documentation of written notification was given to Resident #1 or
Resident #1's representative.
In an interview on 07/22/2024 at 1:11 PM, Resident #1's family representative stated that she filed
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676341
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Caprock Nursing & Rehabilitation
900 College Ave
Borger, TX 79007
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
a grievance on 07/11/2024 with the facility. The representative stated that she did not receive any outcome
of the grievance and when she asked the DON for a copy of the grievance resolution, she was told she
could not have that information. The representative also stated that Resident #1 did not receive any written
documentation about the outcome of the grievance.
In an interview on 07/23/2024 at 3:47 PM, Resident #1 stated that he had filed a grievance with the facility.
Resident #1 was unsure what date the grievance was filed but stated he had not received any
documentation that the grievance was concluded and stated that no one had come talk to him about the
grievance.
In an interview on 07/23/2024 at 6:41 PM, CNA A stated that the ADM was responsible for the grievances.
CNA A stated that if a resident or staff wants to file a grievance, she informs administration.
In an interview on 07/24/2024 at 9:05 AM , The ADM stated that he did not give Resident #1 a written
explanation of the findings of the grievance but verbally talked to the resident. The ADM stated he was the
grievance official, and the SW enters the information from the grievances.
In an interview on 07/24/2024 at 9:15 AM, the DON stated the SW usually takes care of the grievances, but
the ADM was responsible for letting the resident know the conclusion. The DON stated that a possible
negative outcome would be that the resident would feel a lapse of communication in the facility, that a
resident may forget that they were talked to about the grievance and feel that their grievance wasn't heard.
The DON stated she did not give the information regarding the grievance to Resident #1's representative
because the ADM talked to Resident #1 about the grievance. Since Resident #1 was cognitively intact, the
resident would understand the findings.
In an interview on 07/24/2024 at 9:20 AM, the ADON said that a possible negative outcome for not giving a
resident written notification for a filed grievance would be that a resident may not feel that the grievance
was resolved.
In an interview on 07/24/2024 at 9:30 AM, The SW stated that she was responsible for the grievances, but
the ADM was responsible for the notification. The SW stated that a possible negative outcome for not giving
a written document of the resolved grievance that a resident could forget that the ADM talked to them about
the grievance.
Record Review of facilities policy Grievance dated 11/2/2026 revealed the following: .The grievance official
of the facility is the administrator or their designee .The grievance official will issue written grievance
decisions to the resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676341
If continuation sheet
Page 2 of 2
