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F0565
E

Failure to Address and Communicate Resident Council Concerns

Wilmington, North Carolina Survey Completed on 04-24-2025

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 act upon and communicate follow-up regarding concerns raised by the Resident Council over a six-month period. Resident Council meeting minutes consistently documented concerns about meal tickets not matching what was served, the taste of food, insufficient staff during mealtimes, and the unavailability of always available menu items. Although concern forms were reportedly filed and meeting minutes were signed by the Administrator, there was no documentation or evidence that these concerns were addressed or that any follow-up was communicated back to the Resident Council. Interviews with the Resident Council President and the Activity Director confirmed that concerns were regularly recorded and concern forms were completed, but no resolutions or responses were provided to the council. The Resident Council President expressed frustration over the lack of follow-up, stating that management did not address the council's concerns. The Activity Director indicated that she submitted concern forms and meeting minutes to the Administrator but did not see any follow-up or action taken. The Social Services Director reported not being involved in the process and had not seen any concern forms or attended meetings. The Administrator acknowledged that the Social Services Director was previously responsible for addressing Resident Council concerns, but after the previous Social Services Director left, the process lapsed. The Administrator admitted to not attending Resident Council meetings, not being involved in addressing concerns, and having no documentation to show that grievances were addressed. Despite signing the meeting minutes, the Administrator could not confirm awareness of the repeated concerns expressed by residents.

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