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F0609
D

Failure to Timely Report Alleged Verbal Abuse to State Agency

Watertown, Wisconsin Survey Completed on 10-06-2025

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

An allegation of verbal abuse was made by a resident with intact cognition and multiple medical conditions, including spina bifida, paraplegia, and a stage 4 pressure ulcer. The resident reported to staff that a CNA repeatedly addressed them as "stupid" in the presence of other staff members. The resident informed an unidentified staff member about the name-calling, who stated they would notify the social worker and ensure the CNA did not work with the resident that day. However, the social worker was not made aware of the allegation until later, and the Director of Nursing was also not informed until the day of the surveyor's investigation. The facility's policy requires that all allegations of abuse be reported to the State Agency immediately, or within specific timeframes depending on the severity. Despite this, the allegation was not reported to the State Agency as required. The staff member who initially received the report relayed the information to the Director of Nursing, but there was a delay in both internal and external reporting. The correct CNA was only identified and suspended after the surveyor's involvement, indicating a failure to follow the facility's abuse reporting protocol.

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