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F0600
D

Failure to Protect Resident from Verbal Abuse and Rough Handling by CNA

Black River Falls, Wisconsin Survey Completed on 12-03-2025

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

A deficiency occurred when a Certified Nursing Assistant (CNA) engaged in verbal abuse and rough handling of a resident who required extensive assistance with activities of daily living due to diagnoses including renal cancer, urine retention, and hydronephrosis. The resident reported feeling like an animal during care and expressed fear of staff, stating that staff were rough and used inappropriate language. The resident also indicated that they had reported these concerns to facility leadership. Multiple staff interviews confirmed that the CNA was observed swearing at the resident and handling them roughly during care. A housekeeper witnessed the CNA cursing at the resident and placing their legs harshly on wheelchair pedals, and reported hearing the CNA yelling from down the hall. The housekeeper reported the incident to a Registered Nurse (RN), who in turn reported it to the Nursing Home Administrator (NHA). However, neither the housekeeper nor the RN intervened to remove the resident from the situation or to have the CNA leave the room at the time of the incident. Despite the allegations and reports, the CNA was not removed from resident care during the investigation. The facility's investigation was limited, consisting of only three handwritten staff interviews without times or signatures, and did not include interviews with other staff or residents. The incident was not reported to the State Agency as required, and the NHA acknowledged that the event constituted an allegation of abuse but did not take further investigative or protective actions.

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