F0585

D

Failure to Provide Required Follow-Up on Grievance Regarding Call Light Disconnection

Brookfield, Wisconsin Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to honor a resident’s right to voice grievances without reprisal by not following its own grievance policy for a resident whose POA reported concerns. The facility’s policy required that all grievances, whether verbal or written, receive immediate priority, be investigated with efforts toward resolution within seven days, and that the resident be provided with verbal follow-up including the name of the department head conducting the investigation, the steps taken, and the final results. The resident, who had an activated POA, was admitted on a specified date, and the POA reported to surveyors that in approximately October a CNA had purposely unplugged the resident’s call light and that she was concerned about the resident’s care. The POA stated she had informed the facility social worker at the time of the event.

During a state survey, the POA told surveyors she had not received any information from the facility and was unaware of what was happening with the resident’s care. The facility only submitted a report to the State Agency after surveyors notified them of the complaint on a later date, at which point the facility conducted an investigation and submitted findings to the State Agency. The Nursing Home Administrator acknowledged awareness that the POA had concerns but stated that administration was not aware of the concern until surveyors brought it to their attention and that the facility had not followed up with the POA because they were unable to reach her. The POA reported that she had received no updates at any point during the investigation. As a result, the facility did not provide the required feedback or timely resolution of the grievance as outlined in its grievance policy.