Health inspection·October 12, 2023

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 observation, interview and record review, the facility failed to ensure that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to file a grievance for Resident #1 when the family of the resident made complaints. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Review of Resident #1's Face sheet, dated 10/12/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dementia and heart failure. Review of Resident #1's MDS assessment, dated 08/10/23, reflected the resident had severely impaired cognition. Review of Resident #1's Care plans reflected there was no care plan related to cognition. Review of the facility Grievance Report forms for July 2023 through September 2023 revealed there were no grievances documented for Resident #1. An observation and interview on 10/12/23 at 12:25 PM revealed Resident #1 was in bed and was being assisted by facility staff to eat. The family of Resident #1 was at the bedside. The family said they had multiple complaints about the facility and the care the facility provided for the resident. The family said they filed a grievance in December 2021, and nothing happened. The family said following that issue, they started sending emails to the facility with their concerns about Resident #1's care to have a paper trail. The family said they did not always get a response. An interview on 10/12/23 at 1:40 PM with the DON revealed she had received multiple complaints from the family of Resident #1. She said they were continuous complaints and were received on a daily basis. She said she addressed the issues but did not file grievances about the complaints because of Page 1 of 2 676466 676466 10/12/2023 Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149

F 0585 the excessive number of complaints. Level of Harm - Minimal harm or potential for actual harm An interview on 10/12/23 at 4:05 PM with the Administrator revealed he received numerous complaints from the family of Resident #1. He said he had the emails on his phone, and he said he addressed the complaints. He said he did not file the complaints as grievances because he received so many of them. Residents Affected - Few Review of the facility policy, Grievance Policy and Procedure, not dated, reflected: The resident/responsible party has the right to voice grievances to the facility or other agency or entity that hears grievances without fear of reprisal or discrimination. Such grievances include those with respect to treatment or care which has not been furnished, the behavior of staff, and of other residents, and other concerns regarding their LTC facility stay. This facility will make prompt efforts to resolve the grievance, including those with respect to the behavior of other residents within 7-14 days. All grievances must be investigated and may be oral or written and anonymous. The resident/responsible party has a right to obtain a written decision regarding their grievance . 676466 Page 2 of 2