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F0609
D

Failure to Timely Report Abuse, Neglect, or Theft Allegations

Kenosha, Wisconsin Survey Completed on 05-29-2025

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 reportable allegations of abuse, neglect, or theft were reported to the State Agency (SA) in a timely manner and did not notify law enforcement as required. In one instance, a cognitively intact resident with multiple medical conditions was subjected to verbal abuse by a CNA, which was witnessed by an LPN. Although the CNA was immediately removed from the facility and the Administrator and DON were contacted, the mandated 24-hour report to the SA was not submitted until five days after the incident. The Administrator attributed the delay to system issues with the State's online reporting portal and did not notify law enforcement. In another case, a cognitively intact resident reported missing cash after staff returned money that had been given to them. The incident was reported to the SA, but law enforcement was not notified, as the Administrator was unaware of the requirement to do so when a crime is suspected. Additionally, a third cognitively intact resident reported feeling verbally abused by staff, with the information coming from a hospital assessment. The Administrator investigated the incident but did not report it to the SA, believing it was unnecessary since the resident had not reported it directly to the facility. The facility's policy required immediate reporting of all alleged violations to the Administrator, SA, adult protective services, and law enforcement when applicable, but these procedures were not consistently followed.

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