F0585

B

Failure to Provide Required Written Grievance Decisions and Documentation

Kannapolis, North Carolina Survey Completed on 03-18-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to follow its own grievance policy and federal requirements to provide written grievance decisions to residents or their representatives. The facility’s grievance policy dated 11/14/25 states that the Grievance Official will issue a written decision at the conclusion of each investigation, including the date the grievance was received, investigative steps taken, a summary of findings or conclusions, whether the grievance was confirmed, any corrective action taken or to be taken, and the date the written decision was issued. Review of grievance logs from April 2025 through February 28, 2026, showed that these required elements were not documented for multiple grievances, and there was no indication that written grievance summaries were provided to complainants.

For one cognitively intact resident, a grievance was filed regarding having leftover change from a shopping trip deposited back into his resident funds. The grievance form did not indicate whether the grievance was resolved, how or when the results were communicated to the resident, or whether a written summary was provided. The Business Office Manager reported that the funds were deposited and that she verbally informed the resident but did not provide anything in writing. The resident stated he could not recall if anyone discussed the resolution with him and that he had never received or been offered a written resolution of his grievance.

For another resident with moderately impaired cognition, multiple grievances were filed by the resident’s representative regarding missing clothes, notification concerns, and issues with showers, room cleanliness, and receiving statements. The grievance forms either lacked indication of resolution or did not document how or when the results were communicated, and there was no indication that written summaries were provided. The representative reported that concerns were typically addressed by phone or in person and that she had never received anything in writing and was not always satisfied with the resolutions. A third cognitively intact resident filed a grievance about not receiving incontinence care on a specific date; the grievance form did not indicate if it was resolved or how and when the results were communicated. This resident stated that the facility normally talked to her about results but that she had never received anything in writing. The social worker responsible for maintaining the grievance logs stated she provided resolutions by phone or in person and had not been issuing written grievance resolutions because she was unaware this was required, and the Administrator similarly stated she was not aware that written grievance resolutions were required.