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F0565
E

Failure to Address Resident Council Grievances and Call Light Concerns

Milwaukee, Wisconsin Survey Completed on 06-10-2025

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 grievances raised during resident council meetings and did not demonstrate a response or provide rationale for their actions regarding these concerns. Resident council meeting minutes over several months documented repeated complaints about staff not passing snacks, delayed call light responses, staff using phones while providing care or sitting at the nurses' station, and staff rarely being present on the units. Despite these ongoing concerns being raised in multiple meetings, there was no documented evidence that the facility addressed or responded to the issues. Additionally, call light audits were conducted, but the results were not documented or shared. Multiple residents, all cognitively intact according to their MDS assessments, reported persistent problems with staff not responding to call lights in a timely manner and staff being distracted by personal phone use. Some residents filed formal grievances, which were logged, but interviews revealed that residents felt their concerns were not addressed and that the issues continued. The facility administrator stated that grievances from resident council were supposed to be resolved through the grievance process, but could not provide documentation of actions taken or outcomes related to the concerns raised.

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