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F0565
E

Failure to Address and Communicate Resident Council Concerns

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 act upon and communicate efforts to address concerns reported by the Resident Council over a period of seven out of nine months reviewed. Resident Council meeting agendas and minutes repeatedly documented resident concerns, including issues such as lack of sugar-free desserts, outdated call bell systems, slow call bell response times, broken laundry equipment, malfunctioning air conditioning in resident rooms, insufficient staffing, lack of staff assistance after meals, and limited meal choices. Despite these concerns being voiced and recorded during meetings attended by various department heads, there was no documentation of follow-up actions or communication of resolutions to the Resident Council in subsequent meetings. Interviews with residents revealed ongoing frustration and a perception that their concerns were ignored, as they consistently received responses such as "I'll look into it" without any observable action or feedback. Residents reported feeling that their input did not make a difference, and that management failed to address or resolve the issues raised during the meetings. One resident, who attended all meetings, specifically expressed frustration with the lack of follow-up and resolution to the council's concerns. Staff interviews further confirmed the deficiency. The social worker responsible for recording grievances stated that concerns voiced during Resident Council meetings should have been documented as grievances and forwarded to the appropriate department managers for investigation and resolution. However, a review of the grievance logbook revealed that no grievances had been completed from the Resident Council meetings. The social worker who conducted the meetings admitted to not being trained in overseeing the process or addressing grievances, and the administrator acknowledged the absence of a formal process to address and resolve Resident Council concerns.

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