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F0565
E

Failure to Address and Communicate Resolutions to Resident Council Grievances

Wilmington, North Carolina Survey Completed on 04-17-2025

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 address and communicate resolutions to grievances reported during Resident Council meetings for 10 out of 12 months reviewed. Review of Resident Council meeting minutes from April 2024 through March 2025 showed that concerns raised by residents, such as missed scheduled showers, staff using headphones or cell phones during care, delayed response to call lights, and issues with meal timeliness, were repeatedly documented without any follow-up or discussion of resolutions in subsequent meetings. The minutes consistently lacked documentation of how previous concerns were addressed, and residents reported that their ongoing issues were not being discussed or resolved at the start of each meeting. Interviews with residents confirmed that their concerns had persisted for months without resolution or feedback from facility staff. The newly hired Activities Director and the Administrator, both of whom started their roles recently, were unaware of how previous concerns had been managed and had no documentation to show that grievances were addressed. Residents continued to experience the same issues, including late breakfast service, unfulfilled shower schedules, delayed call light responses, and staff using headphones during care, indicating a pattern of unaddressed resident grievances over an extended period.

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