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F0609
D

Failure to Timely Report Alleged Abuse Incident

West Salem, Wisconsin Survey Completed on 09-16-2025

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 ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframe. According to the facility's Abuse Prevention Program policy, allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, and all other allegations must be reported within 24 hours. In this incident, a resident with intact cognitive function reported that a CNA spoke to her in a condescending and aggressive manner, grabbed her wrist tightly despite her requests to let go, and refused to leave the room when asked multiple times. The resident described the interaction as abusive and stated she felt afraid during the incident. Multiple staff members, including another CNA and an LPN, witnessed the event and corroborated the resident's account. The LPN observed the resident visibly upset, with watery eyes and trembling, and noted slight redness on the resident's wrist. The LPN also reported that the CNA continued to work the remainder of the shift after the incident. The LPN promptly reported the incident to the Director of Nursing and began gathering witness statements for an investigation. Despite the prompt internal reporting, the facility did not report the incident to the State Survey Agency within the required 24-hour period. The self-report to the state was made three days after the incident occurred, which is not in compliance with the facility's policy or federal regulations. This delay in external reporting constitutes the deficiency identified by the surveyors.

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