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F0585
D

Failure to Document Grievance Investigations and Outcomes

Windsor, North Carolina Survey Completed on 05-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain evidence of grievance investigations and decisions for three residents who filed grievances. Each grievance form reviewed was incomplete, lacking documentation of the investigation, outcome, or recommendations for corrective action. The facility's grievance policy requires that investigations include employee accounts of alleged incidents and recommendations for corrective action, but these elements were missing from the records for all three residents. The grievances included concerns about staff responsiveness, food quality, missing personal items, and lack of assistance with toileting. Interviews with the Social Worker and Administrator revealed a breakdown in the grievance handling process. The Social Worker assisted residents in filling out the initial grievance forms and then forwarded them to the appropriate department head for investigation. After the department head completed the investigation, the Administrator was supposed to review and sign off before the forms were filed. However, both the Social Worker and Administrator were unsure how incomplete grievance forms ended up being filed, indicating a lack of oversight and follow-through in the grievance process.

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