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F0609
D

Failure to Report Injury of Unknown Source

Clinton, Wisconsin Survey Completed on 12-16-2025

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 that all alleged violations involving abuse, neglect, and injuries of unknown source were reported immediately to the State Agency, as required by both regulation and facility policy. A resident with multiple diagnoses, including Parkinson's disease, dementia, and a history of falls, sustained an injury of unknown source on two occasions. On the first occasion, the resident returned from a dental appointment and began complaining of pain in the right lower extremity, with staff and hospice nurses noting swelling, bruising, and pain. Despite these findings, there was no clear documentation of an incident report or a nurse progress note detailing the injury, and staff were uncertain about the cause of the injury. Interviews with various staff members, including the Business Office Manager, LPNs, and the Assistant Director of Nursing, revealed inconsistent accounts regarding the incident. The staff transporting the resident and the dental office staff did not recall any incident during the outing. Nursing staff noted the resident's complaints and physical findings but did not complete or document an incident report, and there was confusion about who was responsible for documentation and assessment. The Director of Nursing later confirmed that the injuries were of unknown source and acknowledged that they were not reported as required. The facility's own policy mandates immediate reporting of injuries of unknown origin to the State Agency, including an initial allegation report and a five-day final investigation report. Despite being aware of the resident's injuries and the lack of a clear cause, the facility did not fulfill these reporting obligations. The Nursing Home Administrator confirmed that the injuries should have been reported but were not, resulting in a deficiency for failure to report suspected abuse, neglect, or injuries of unknown source.

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