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F0585
E

Failure to Provide Accessible Grievance Process for Residents

Kenosha, Wisconsin Survey Completed on 12-03-2025

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 support residents' rights to voice grievances or complaints without discrimination or reprisal. During a resident group interview, several alert and oriented residents stated that they had requested the installation of a grievance box with attached grievance forms to allow for anonymous submissions. Review of Resident Council minutes confirmed repeated requests for accessible grievance forms and a grievance box, with the administrator initially agreeing to provide these. However, observations revealed that only an unlocked suggestion box was available, not a grievance box, and that the suggestion cards did not serve the same purpose as grievance forms. The facility's grievance policy and procedure were found locked in a glass cabinet, making them inaccessible to residents, and no grievance forms were readily available at the nurses' station as claimed by the administrator. Interviews with staff, including a registered nurse and the social service director, indicated that grievance forms were not present at the nurses' station and staff were unaware of their location. The Resident Council President confirmed ongoing requests for a grievance box and forms, emphasizing that residents should not have to ask staff for these materials. The facility's own grievance policy stated that notices of residents' rights regarding grievances should be posted in prominent locations and that grievance forms should be accessible, but these requirements were not met, resulting in a failure to provide residents with a means to file grievances anonymously or without staff knowledge.

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