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F0607
C

Abuse Policy References Incorrect State Regulations

Spring Valley, Wisconsin Survey Completed on 08-08-2025

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 develop and implement an Abuse, Neglect, and Exploitation policy that was compliant with the appropriate state regulations. The policy in use referenced Nebraska reporting regulations and contact information, rather than those for Wisconsin, where the facility is located. This policy was used for staff training and guidance on reporting abuse, neglect, and exploitation, despite the incorrect state references. The Nursing Home Administrator (NHA) confirmed that the policy originated from a management company and was likely intended for a different facility in another state. During interviews, the NHA acknowledged that the facility relied on this incorrect policy and Relias training for staff education regarding abuse and neglect. The surveyor verified that, in practice, self-reports were being made to the correct Wisconsin authorities, but the written policy and training materials did not reflect the correct state requirements. No other policies were identified as being used for staff education on this topic.

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