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F0600
D

Failure to Protect Resident from Verbal Abuse and Inadequate Staff Training

River Falls, Wisconsin Survey Completed on 06-11-2025

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 protect a resident's right to be free from verbal abuse by staff. A resident with severe cognitive impairment, dementia, and other significant medical conditions was subjected to verbal abuse when a registered nurse raised his voice and swore at the resident while providing care. Additionally, a certified nursing assistant was reported to have intimidated the resident and did not attempt appropriate interventions. The incident was reported by another staff member, and the facility's investigation confirmed the occurrence of verbal abuse. The facility did not ensure that all staff were trained on the abuse policy, as evidenced by incomplete staff sign-in sheets for abuse education and reporting. Out of 78 staff employed at the time, only a portion received documented training following the incident, and some staff, including the involved nurse, were not listed as having received prior abuse training. Furthermore, the facility did not conduct formal audits of staff interactions or knowledge of the abuse policy to prevent further incidents. There was also no written quality improvement or performance improvement plan in place to address or track patterns of abuse occurrences.

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