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F0609
D

Failure to Timely Report Alleged Resident-to-Resident Abuse

Clintonville, Wisconsin Survey Completed on 10-09-2025

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 timely report an allegation of physical abuse involving two residents. On the morning of 7/24/25, one resident placed their arms around another resident's neck, pulled them closer, and pinched their ear. The affected resident appeared upset and tearful, and staff observed that the interaction was unwanted. Despite witnessing the incident, staff did not report it at the time. The abuse was only reported after a subsequent incident occurred later that same day. Review of facility policy indicated that all alleged violations must be reported within two hours to the State Licensing Agency. Interviews with staff, including an LPN and the DON, confirmed that the initial incident was not reported as required, and the LPN acknowledged that reporting the first occurrence might have prevented the second.

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