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F0565
E

Failure to Address Resident Council Grievances on Staff Cell Phone and Ear Bud Use

Waukesha, Wisconsin Survey Completed on 06-09-2025

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 ensure that grievances and recommendations raised during Resident Council meetings were acted upon promptly, as required by facility policy. Over a three-month period, Resident Council meeting minutes consistently documented concerns from multiple residents regarding staff using ear buds and cell phones while providing care, including during medication administration and personal care tasks. Residents reported that this behavior occurred frequently, with some stating it happened daily or several times a week, and expressed feelings of frustration, irritation, and a perception that their care was negatively impacted. During interviews, residents confirmed that the issue persisted and that the facility's response was limited to verbal assurances that staff would be spoken to about the matter. Despite the recurring nature of the complaints, facility leadership, including the DON and NHA, acknowledged awareness of the concerns but indicated that their approach was to address incidents as they were observed rather than implementing a broader or systematic follow-up in response to the Resident Council's documented grievances. Documentation provided to surveyors showed that staff education on cell phone and ear bud use had occurred, but there was no evidence of a process improvement plan or additional corrective action following the continued reports from residents. The facility's policy required action on Resident Council concerns and communication of decisions back to the Council, which was not demonstrated in this case.

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