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F0609
D

Failure to Timely Report Alleged Abuse and Threats

Middleton, 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

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by policy. In one instance, a resident's Power of Attorney (POA) reported an alleged sexual abuse incident involving a staff member, but the facility did not report this allegation to the State Agency or law enforcement, despite the administrator acknowledging that the allegation met the definition of sexual abuse and was a reportable incident. Documentation showed that the concern was initially treated as a grievance, and while an internal investigation was conducted, the required external reporting did not occur. In another case, a cognitively intact resident reported to therapy staff that another resident made a threatening statement, which was recognized by staff and administration as verbal abuse and a reportable incident. However, this allegation was also not reported to the State Agency within the required timeframe. The facility's own policy defined such statements as verbal abuse and required immediate reporting, but the incident was only documented as a grievance without evidence of timely external notification.

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