F0609

E

Failure to Report Multiple Abuse Allegations to State Agency

Suring, Wisconsin Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report multiple allegations of abuse to the State Agency (SA) as required by its Abuse, Neglect, and Exploitation policy. The policy, revised 7/1/25, directs staff to report all alleged violations to the Administrator, SA, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other events. Despite this, allegations that one CNA was rough with care and verbally abusive were not reported to the SA as facility-reported incidents.

One cognitively intact resident with a history of left humerus fracture, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis reported being physically and mentally abused and yelled at for incontinence since admission. This resident stated that the CNA was rough with care, refused to get the resident out of bed to use the bathroom, forced use of a bedpan, and pinched or jabbed the resident’s hip during care, causing pain. The resident reported these concerns to the Nursing Home Administrator a few days after admission, stating feeling mentally and physically abused, but did not receive follow-up and did not believe the concerns were taken seriously. The Administrator’s progress note from a care conference documented the resident as anxious and tearful and declining therapy and medications, but did not document the specific concerns about the CNA.

Additional residents with varying levels of cognition and medical conditions, including rheumatoid arthritis, history of stroke, depression, peripheral vascular disease, osteoarthritis, chronic kidney disease, osteoporosis, edema, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with care and that they did not want this CNA in their rooms. Some residents described rough transfers, aggressive assistance with a urinal that caused pain, and fear of the CNA. Family members and multiple CNAs reported that residents had complained about the CNA being rough and short-tempered, and that there was a list of residents who would not allow the CNA in their rooms. A unit manager LPN reported these concerns to the DON. The Nursing Home Administrator, DON, and unit manager acknowledged that several residents did not want the CNA to provide care but attributed this to cultural and racial differences and denied receiving reports that the CNA was rough with care. No allegations of abuse related to this CNA were reported to the SA, despite the facility’s policy requiring such reporting.