F0610

E

Failure to Investigate Multiple Abuse Allegations Against Agency CNA

Suring, Wisconsin Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, or rough care by one agency CNA toward several residents, despite its Abuse, Neglect, and Exploitation policy requiring immediate and comprehensive investigations. The policy directs the facility to initiate an immediate investigation when there is suspicion or reports of abuse, to identify and interview all involved persons, and to provide complete documentation. Surveyors found that for six residents, the facility either did not initiate an investigation at all or conducted incomplete investigations that lacked required interviews and documentation.

One cognitively intact resident with a history of left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis reported feeling physically and mentally abused by a specific CNA. This resident stated the CNA was rough with cares, 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. The resident reported these concerns directly to the NHA a few days after admission and specifically stated feeling physically and mentally abused. The NHA’s progress note from a care conference documented anxiety and tearfulness and offered telehealth therapy and medication, but did not document the specific abuse concerns or any abuse investigation. Review of facility-reported incidents (FRIs) and grievances showed no investigation related to this resident’s abuse allegation.

Another resident with severely impaired cognition and an activated POA for healthcare was the subject of an abuse allegation reported by the POA to the local police, who then notified the facility. The POA alleged abusive practices, including discontinuation of therapy and administration of medication to sedate the resident. The facility submitted an FRI and initiated an investigation; however, the investigation lacked interviews with the resident, the POA, or other residents and staff. The NHA later stated that resident interviews had been completed but could not initially locate them, and confirmed that staff interviews were not done. When the interviews were produced, they were undated and contained only general questions that did not address the specific allegations of overmedication and discontinuation of therapy.

Additional residents with varying levels of cognitive function and medical conditions, including rheumatoid arthritis, stroke history, osteoarthritis, chronic kidney disease, osteoporosis, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with cares. One resident and that resident’s family reported the CNA was rough and that the resident did not want the CNA in the room; another resident reported the CNA worked too fast and was rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA pushed a urinal too hard into the resident’s testicles; and another resident reported being fearful of the CNA and not wanting the CNA in the room. These concerns were reportedly communicated multiple times to unidentified CNAs, nurses, and administration. Staff CNAs and a unit manager LPN confirmed that several residents had reported the CNA was rough with cares and that there was a list of residents who did not allow the CNA in their rooms, and that these concerns were reported to nursing and management. Despite this, review of FRIs and grievances revealed no investigations for these residents’ allegations, and the NHA, DON, and unit manager attributed residents’ refusals of care from the CNA to cultural and racial differences, while also confirming that the facility did not thoroughly investigate the allegations of rough care and abuse.