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F0585
D

Failure to Provide Written Grievance Summaries to Residents

Pembroke, North Carolina Survey Completed on 11-21-2025

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 provide written grievance summaries to residents or their representatives as required by its own grievance policy. For two residents who were both severely cognitively impaired, grievances were filed regarding concerns such as inadequate nail care, improper dressing for appointments, and lack of assistance with bathroom transfers. In both cases, the grievance logs and forms either lacked documentation of written notification of the resolution or contained written summaries that did not correspond to the specific concerns raised. Staff interviews revealed that key personnel, including the Administrator, Director of Nursing, and Social Worker, were unaware of the requirement to provide written grievance summaries to residents or their representatives. Instead, resolutions were communicated verbally or not at all, and written documentation was either missing or incomplete. This resulted in the facility not adhering to its policy and regulatory requirements for grievance resolution documentation.

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