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F0607
D

Failure to Implement Abuse Prevention Policies Following Family Member's Verbal Abuse

Madison, Wisconsin Survey Completed on 12-05-2025

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 implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after being made aware that a family member verbally abused a resident—including yelling, swearing, and throwing a hanger in the resident's room—the facility did not take steps to protect the resident from further abuse, did not report the incident, and did not conduct an investigation as required by their abuse prevention policy. Witnesses, including another resident and a visitor, reported the incident to Social Services, describing the family member's behavior as abusive and distressing. Despite these reports, the facility did not interview the resident involved, citing the family member's status as activated power of attorney and their instruction that staff could not speak to the resident without their presence. Staff acknowledged the incident could be considered abuse and confirmed that no interventions or plans were put in place to ensure the resident's safety. The facility also failed to report or thoroughly investigate the allegation, contrary to their own policies and federal requirements.

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