Health inspection·July 24, 2024

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 Page 1 of 2 676341 676341 07/24/2024 Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007

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 . 676341 Page 2 of 2