F0609

D

Failure to Report Alleged Neglect to State Agency

Manitowoc, Wisconsin Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency (SA) as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/15/22, states that the facility will designate a leadership position responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials, and that all alleged violations must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. The policy further specifies that allegations involving abuse or serious bodily injury must be reported immediately but not later than two hours after the allegation is made, and all other reportable events must be reported not later than 24 hours, with final investigation results reported within five working days as required by state agencies.

For one sampled resident (R1), an allegation of neglect involving a CNA (CNA-E) on 12/23/25 between 2:00 PM and 9:00 PM was reported internally to the Nursing Home Administrator (NHA-A) but was not reported to the SA. R1 had dementia, chronic kidney disease with heart failure, anxiety, and depression, and a recent MDS dated 12/18/25 showed a BIMS score of 0/15, indicating severely impaired cognition; R1 also had an activated POA. On 1/28/26, the surveyor requested the facility’s report to the SA regarding the allegation that R1 did not receive care from CNA-E during the specified time period and was unable to interview R1 due to cognitive impairment. During an interview on the same day, NHA-A acknowledged not reporting the allegation of neglect to the SA and stated the belief that reporting was unnecessary because the facility had determined the incident was a miscommunication issue.