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F0609
D

Failure to Timely Report Alleged Staff-to-Resident Abuse

Brookfield, Wisconsin Survey Completed on 06-10-2025

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 submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within the required two-hour timeframe for one resident. According to facility policy, any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be reported immediately, defined as no later than two hours after forming the suspicion if serious bodily injury is involved. In this case, a resident with severe cognitive impairment and a history of chronic kidney disease and major depressive disorder reported being hit in the head by a CNA during care. The allegation was discovered by facility management after the resident’s POA reported observing the incident on camera and after the resident made a direct accusation to staff. Facility documentation shows that the incident was discovered at approximately 9:08 AM, but the initial report to the state survey agency was not submitted until 1:27 PM, exceeding the two-hour reporting requirement. The administrator confirmed that the report was delayed because she waited to obtain more details before submitting it. The deficiency centers on the failure to promptly report the abuse allegation as required by both facility policy and regulatory standards.

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