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F0565
E

Failure to Address and Communicate Resolutions for Resident Concerns

Benson, North Carolina Survey Completed on 11-20-2025

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 resolve and communicate resolutions for repeat concerns raised by residents during organized group meetings, specifically regarding call-light response times, housekeeping services, and dietary services. Over a six-month period, meeting minutes and communication forms showed that concerns were repeatedly voiced by residents, but there was inconsistent or absent documentation of follow-up actions or resolutions. In several instances, only select issues were addressed, while others, such as dietary and housekeeping concerns, were not documented as resolved. Residents reported that their concerns remained unaddressed over multiple months, and they did not receive updates about any actions taken. Residents expressed ongoing dissatisfaction with the facility's handling of their concerns, particularly regarding food quality, call light response, and room cleanliness. They reported feeling unable to voice dietary concerns during Resident Council meetings due to the creation of a separate Dietary Council, which they felt was not effective. Residents described the Dietary Manager as unapproachable and dismissive, and stated that they were not informed about the outcomes of their complaints. There was also a lack of formal documentation or minutes for Dietary Council meetings, and residents could not recall when these meetings last occurred or if the Dietary Manager attended. Interviews with staff, including the Activities Director, Dietary Manager, and Administrator, revealed a lack of consistent processes for documenting, tracking, and communicating the resolution of resident concerns. The Activities Director did not bring resolved or pending issues back to subsequent Resident Council meetings and did not keep formal records of Dietary Council meetings. The Administrator was unaware of the specifics of concerns discussed in Dietary Council meetings and did not consistently document follow-up actions. This lack of communication and documentation contributed to residents' perceptions that their concerns were not being addressed.

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