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F0609
D

Failure to Timely Report Alleged Verbal Abuse

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 implement its policies and procedures for the timely reporting of an allegation of verbal abuse in accordance with section 1150B of the Act. Specifically, a certified nursing assistant (CNA) witnessed a registered nurse (RN) raising his voice and swearing at a resident with severe cognitive impairment during care. The CNA did not report the incident immediately or within the required two-hour timeframe, instead waiting until the following morning to inform the Assistant Director of Nursing (ADON). The ADON then reported the incident to the Director of Nursing (DON), who subsequently notified the Nursing Home Administrator (NHA). The incident was not reported to local law enforcement as required by state law, and the facility's investigation was not completed and reported to the state agency until several days later. The resident involved had significant medical conditions, including a nondisplaced femur fracture, dementia with severe cognitive impairment, and required moderate assistance with daily activities. The Minimum Data Set (MDS) assessment documented the resident's severe cognitive impairment and need for extensive support. The failure to report the alleged verbal abuse in a timely manner, as outlined in facility policy and federal requirements, constituted a deficiency in the facility's abuse reporting procedures.

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