F0585

D

Failure to Document and Investigate Resident Grievances Related to Alleged Rough Care

West Allis, Wisconsin Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its grievance policy and to address care concerns raised by a resident’s representative. The facility’s written grievance policy, revised 2/12/25, requires that when a grievance is noted verbally or in writing, staff attempt to resolve the issue or direct the complainant to appropriate leadership, notify the Grievance Officer, record identifying information and the nature of the matter, route the grievance for investigation, and ensure efforts toward resolution within seven days, including verbal follow-up to the resident. Surveyor review of the grievance log on 2/3/26 showed no documented concerns from the resident or the resident’s representative, despite allegations that concerns had been reported to facility staff.

According to the report, the resident’s representative contacted the Director of Care Transitions on two occasions to report concerns about the resident’s care. After care provided on 11/13/25, the representative reported on 11/14/25 that staff became very frustrated when the resident needed frequent adjustments in bed, called the resident names, and yelled at the resident for using the call light and “wasting” staff time by calling so often. Later, following care on 12/22/25, the representative again contacted the Director of Care Transitions on 12/23/25, alleging that a CNA entered the resident’s room extremely agitated and aggressive about the resident having pushed the call light, then came behind the resident, grabbed the resident around the torso, and yanked the resident backward in bed, which the representative stated resulted in fractures to the resident’s left 7th and 8th ribs. The representative reported to the State Survey Agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the day after the second incident.

During interviews, the Director of Care Transitions acknowledged remembering conversations with the resident’s representative but did not recall the details, did not take notes, and stated he did not work inside the buildings or know the grievance process, and that he would typically forward an email to the DON or Administrator. He had no documentation in his phone or email showing that he communicated these concerns. The DON stated she had spoken with the representative about the 12/22/25 incident, reviewed the resident’s medical chart, and understood the representative wanted to know how the rib fractures occurred, but she did not consider the questions to be an allegation of abuse or a grievance to address, despite the representative’s concern that the CNA’s hurried and angry repositioning could have caused the fractures. The Administrator later acknowledged that the concerns brought forth by the representative should have been handled as a formal grievance and investigated, but no grievance entry, investigation, or documented resolution was found for these concerns.