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F0609
D

Failure to Report Alleged Staff-to-Resident Abuse

Manitowoc, Wisconsin Survey Completed on 11-24-2025

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 report an allegation of staff-to-resident abuse to the State Agency as required by both facility policy and state and federal regulations. A resident, who had intact cognition and was their own decision maker, reported that during a medical transport, two staff members argued with each other, used vulgar language, and then yelled at the resident in a threatening manner not to disclose the incident. The resident reported this event to facility staff but did not receive any follow-up or investigation regarding the allegation. Upon review, the facility's grievance file did not contain any documentation related to the resident's report of abuse. Interviews with the Director of Nursing confirmed that the incident was reported to the former Nursing Home Administrator, but there was no evidence that the required report to the State Agency was made. The current Nursing Home Administrator acknowledged that the allegation should have been reported in accordance with policy and regulations, but it was not.

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