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.
F585 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F585 more often than its own record predicts
Versus expected share1.28×
1.28 times the share F585 takes of citations nationally.
Share of North Carolina citations0.82%
Of every deficiency written in North Carolina in 2025, this is the portion that was F585.
North Carolina0.82%
National0.64%
Share of all citations that were F585.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F585 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternMarch 27, 2024
Based on record review and Resident, Resident Representative (RR) and staff interviews the facility failed to implement grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 the facility was running out of her Methadone. The Director of Nursing (DON) was assigned the grievance and on 12/01/23 confirmed Resident #21 had Methadone in the medication cart, and it had been documented as administered. The DON did not interview the resident or determine if there had been any supply issues with Resident #21's Methadone. Due to the lack of investigation this problem continued. Resident #21 reported she experienced terrible/awful pain of greater than ten on a scale of 1 to 10. …
E · No harm, potential for more than minimal, patternJuly 20, 2026
Based on record review, resident, Resident Representative (RR), and staff interviews, the facility failed to ensure a written grievance decision included all required components and to provide a written grievance summary for 7 of 7 resident reviewed for grievances (Resident #11, Resident #2, Resident #41, Resident #43, Resident #50, Resident #28 and Resident #85).
The findings included:
Review of the facility policy dated 07/01/2018 titled Resident Grievance Policy indicated the Administrator was responsible for overseeing, directing and investigating grievances in a prompt manner; reviewing the results of the grievance investigations for conclusion; initiating corrective measure or actions; and ensuring the resident or resident representative is notified timely of the results of the… …
B · No harm, potential for minimal, patternMarch 18, 2026
Based on record reviews and Resident Representative (RR), resident and staff interviews, the facility failed to indicate if grievances had been resolved, how the results were communicated to the complainant, when the results of the grievances had been provided to the complainant and also failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #52, #69 and #39). The findings included:
A review of the facility grievance policy, dated 11/14/25, included, in part, In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. …
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