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F0609
D

Failure to Timely Report Alleged Abuse and Denial of Care

Berlin, Wisconsin Survey Completed on 09-10-2025

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

Staff failed to report an allegation of abuse in a timely manner for one resident. A Certified Nursing Assistant (CNA) witnessed another CNA enter a resident's room, yell, point, and swear at the resident, and instruct the resident to urinate in their brief. The resident, who had intact cognition and was responsible for their own healthcare decisions, reported that this CNA had previously told them to urinate in their brief. The incident occurred in the early morning, but the witnessing CNA did not immediately report the event to administration as required by facility policy. Instead, the CNA waited until returning to the facility later that day to report the incident to a Registered Nurse (RN), several hours after the event took place. The facility's policy requires immediate reporting of any witnessed or reported abuse to the Administrator, with allegations of abuse to be reported to the State Agency within two hours. The investigation confirmed that there was a delay in care for the resident, as the CNA who committed the abuse did not provide assistance or change the resident's brief when requested. The investigation also substantiated that the CNA acted deliberately and with willful intent by yelling at the resident and denying care.

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