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F0585
B

Failure to Provide Written Grievance Summaries to Resident's Responsible Party

Wilmington, North Carolina Survey Completed on 09-18-2025

Penalty

Fine: $99,600
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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 a resident's responsible party (RP) after grievances were submitted, as required by facility policy. The policy states that the person filing a concern has the right to receive a written summary detailing the concern, investigative steps, findings, and any corrective actions, with a written response to be provided within three working days. However, review of the grievance log and related documentation revealed that, for at least one grievance regarding a malfunctioning air-conditioning thermostat, the written summary and notification sections were left blank, and there was no evidence that a written summary was provided to the RP. Interviews with facility staff, including the Maintenance Director and Social Worker, confirmed that grievances and concerns reported by the resident's RP were resolved verbally or through email, but no written summaries were given. The Social Worker stated she was unaware of the requirement to provide written grievance summaries and believed verbal communication was sufficient. The Maintenance Director also indicated uncertainty about whether a written summary was ever provided for the air-conditioning grievance. The RP reported submitting multiple grievances, both verbally and by email, and stated she never received a written summary for any of them. The Administrator acknowledged that the RP should have received written grievance summaries for the reported grievances and admitted to not being fully aware of the policy requirement to provide written findings within three days, even if the grievances were resolved verbally. The resident involved was cognitively intact, and the grievances included issues such as small protein serving sizes, delayed mouthwash provision, lack of feeding assistance, laundry issues, and room temperature concerns. Despite these grievances being addressed verbally or through other means, the facility did not fulfill the policy requirement for written communication of grievance outcomes.

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