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F0585
D

Failure to Investigate and Document Resident Grievance Regarding Missing Personal Items

Sister Bay, Wisconsin Survey Completed on 05-07-2025

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

A resident, who was cognitively intact and able to make their own healthcare decisions, reported to several staff members that seven articles of clothing were missing, including labeled items such as t-shirts, an over-shirt, sweatpants, and a sweatshirt. Despite informing housekeeping and laundry staff, as well as mentioning that some items had been missing since the previous year, no grievance forms were filled out regarding the missing items. The facility's grievance file did not contain any documentation related to these missing articles, and the facility's grievance policy was not provided during the survey. Interviews with staff revealed that the housekeeper, who also worked in laundry, was aware of the missing clothing and had previously addressed similar issues with the former social worker. However, the housekeeper did not notify the Nursing Home Administrator or the Director of Nursing, nor did they complete a grievance form, hoping instead that the items would be found. The Nursing Home Administrator confirmed that staff are expected to fill out grievance forms for missing items, but this procedure was not followed in this case.

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