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F0609
D

Failure to Timely Report Allegation of Neglect

Oak Creek, Wisconsin Survey Completed on 06-04-2025

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 timely report an allegation of neglect involving a resident who was cognitively intact and required partial to moderate assistance for toileting hygiene. The resident reported that she had activated her call light at 5:00 AM to request assistance to use the bathroom, but after waiting for an hour, a staff member told her to use the bathroom in her incontinence brief and did not return. The resident ultimately received assistance around 8:00 AM when her spouse arrived. This incident was documented in the facility's grievance summaries. The Director of Hospitality initially treated the incident as a grievance and submitted it as such on the same day, without recognizing it as potential neglect. The Administrator in Training later determined that the incident should have been reported to the State Agency as neglect, but this was not done until several days after the event. The delay in reporting the allegation of neglect was confirmed through interviews and review of facility documentation, indicating a failure to follow the facility's policy requiring immediate reporting of such incidents.

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