F0565

E

Failure to Resolve and Communicate Resident Council Concerns

Boone, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to resolve and communicate actions taken on concerns and suggestions raised during Resident Council meetings over a period of 10 of 11 reviewed months. Resident Council minutes from February 2025 through January 2026 repeatedly documented resident complaints about showers not being provided as often as desired, food being served late, cold, raw, burnt, or of poor quality, beds not being made, and clothing not being taken to or returned from laundry. Although some Resident Council Concern forms were completed and assigned to departments such as nursing, dietary, and laundry, many forms lacked documentation of what was done to address the concerns, and several months had no concern forms at all despite documented complaints in the minutes.

Across multiple months, the Resident Council minutes showed recurring issues without clear follow-up or documented resolution. In February 2025, residents reported late and cold meals, undercooked food, missed showers, unmade beds, and missing or unwashed clothing; concern forms were created for dietary and nursing, but one form had no description of actions taken and another only contained a signature and date. In March and April 2025, residents again voiced concerns about showers, bed-making, missing clothing, and poor or late meals, yet the facility could not provide any corresponding Resident Council Concern forms. In May 2025, residents added complaints about call bells not being answered for long periods, inadequate room cleaning, ill-fitting bed sheets, small or unappetizing food portions, and lack of requested sandwiches; while some concern forms were completed with general departmental responses, the minutes’ “Pending Updates” sections were often blank, and there was no documentation that specific resolutions were communicated back to residents.

From June through November 2025 and into January 2026, the same categories of concerns—call light response times, staff turning off call lights without providing care, noisy or disruptive staff at night, insufficient showers, inadequate linens and towels, missing clothing, and dissatisfaction with food quality, variety, and timeliness—continued to appear in the Resident Council minutes. For several of these months (June, July, August, September, October, and November 2025), the facility was unable to produce any Resident Council Concern forms despite documented complaints. When concern forms were completed in January 2026 for laundry, nursing, and dietary issues, some contained only a generic statement that labeled clothing was returned daily, and others were left entirely blank for the department response, signature, and date. During a Resident Council group interview, multiple residents agreed that concerns about call bell response times, cold or late food, and missing clothing were recurring and ongoing, and they stated that Resident Council was never provided communication about what was done or being done to address these issues. The Activity Director and Administrator confirmed that concerns were frequently repeated month to month and acknowledged that the documented department responses often did not truly address the issues raised, and that the expected process of documenting and reporting back resolutions in the minutes was not consistently carried out.

The deficiency centers on the facility’s failure to honor residents’ rights related to Resident Council by not effectively resolving and communicating the handling of concerns raised in these meetings. The Resident Council minutes repeatedly documented the same categories of complaints without clear evidence that the facility investigated, resolved, and reported back on these issues in a systematic way. Missing or incomplete Resident Council Concern forms, blank sections for pending updates, and resident reports that they were not informed of any actions taken demonstrate the inaction and lack of communication that led to the cited deficiency.