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F0609
D

Failure to Timely Report Alleged Abuse to State Agency

Milwaukee, 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

The facility failed to ensure timely reporting of an allegation of verbal and mental abuse involving a resident with moderate cognitive impairment and a history of dementia, agitation, and aggression. On the day of the incident, a CNA was observed yelling at and threatening the resident, including raising her fist and making a threatening statement. The incident was witnessed by an LPN, who immediately notified the Executive Director and the DON. The facility's policy required that all allegations of abuse be reported to the state survey agency within two hours of the allegation being made. Despite the policy, the report to the state survey agency was not submitted until more than six hours after the incident occurred. Interviews with facility staff, including the Executive Director and DON, confirmed that the two-hour reporting timeframe was not met. Documentation showed that the incident was recognized as abuse by staff, and the CNA involved was suspended pending investigation. The delay in reporting constituted a failure to follow both facility policy and regulatory requirements for timely reporting of abuse allegations.

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