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F0610
D

Failure to Investigate and Report Sexual Abuse Allegation

Middleton, Wisconsin Survey Completed on 10-08-2025

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 thoroughly investigate and report an allegation of sexual abuse involving a resident. A family member initially raised a concern regarding peri care performed by a CNA without gloves, which was documented as a grievance. This concern was later elevated to an allegation of inappropriate touching of the resident's vaginal area by the same CNA. Despite the escalation to a sexual abuse allegation, the facility did not conduct additional interviews or expand the investigation, and the CNA continued to work with residents during the investigation period. The facility's abuse policy requires immediate protection of the alleged victim, thorough investigation, and timely reporting to the state agency, but these steps were not fully followed. Furthermore, the facility did not submit the required report of the investigation's findings to the state survey agency within the mandated five working days. Documentation shows that the CNA remained on duty after the allegation was made, and education on abuse policies was not completed until several days later. The administrator acknowledged that the incident should have been reported to the state agency when the allegation was elevated, but this was not done in accordance with facility policy and state law.

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