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F0600
J

Failure to Protect Resident from Sexual Abuse Due to Inadequate Reporting and Care Planning

Milwaukee, Wisconsin Survey Completed on 12-13-2025

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 protect a cognitively impaired resident from sexual abuse by another resident with a history of inappropriate sexual behavior. One resident, who had diagnoses of metabolic encephalopathy and dementia and was moderately cognitively impaired, had previously attempted to kiss another resident and was reported to have tried to fondle the breasts of a severely cognitively impaired resident. Despite these incidents, the facility did not implement effective preventive measures or update the resident's care plan to address these behaviors until after a subsequent incident occurred. On a later occasion, staff witnessed the same resident with his hand down the pants of the cognitively impaired resident in a common area. Although staff immediately intervened and separated the residents, prior reports of inappropriate behavior had not been communicated to administration or properly documented. Interviews revealed that some staff were aware of previous incidents but did not report them to administration or initiate an investigation, and other staff were unaware of the need to monitor or separate the residents. The care plan for the resident exhibiting inappropriate behavior was not updated to include interventions for these behaviors until after the most recent incident. The facility's failure to report, investigate, and implement preventive measures following initial incidents allowed further abuse to occur. There was a lack of communication among staff and administration regarding the resident's behaviors, and no safety risk evaluation was completed prior to the most recent incident. The facility did not revise the care plan for the victimized resident after the incidents, and not all caregivers were informed of the need for increased monitoring or separation of the residents involved.

Removal Plan

  • Completed a root cause analysis to identify failure to report abuse to administration and prevent reoccurrence.
  • Assessed each resident and established a care plan and supervision.
  • Established systems to monitor and document frequency of behaviors.
  • Completed assessments as indicated by psych services.
  • Trained facility staff on practices and changes to systems.
  • Established a system for auditing and monitoring along with QAPI.
See complete original report
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