F0609

D

Failure to Report Allegation of Resident Exploitation to State Agency

Two Rivers, 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 exploitation to the State Agency as required by its abuse, neglect, and exploitation policy. The policy, revised 7/15/22, states that all alleged violations, including exploitation and misappropriation of resident property, must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Exploitation is defined in the policy as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The policy further requires that alleged violations be reported immediately, but not later than two hours if they involve abuse or serious bodily injury, or within 24 hours if they do not, and that results of investigations be reported to government agencies within five working days.

The incident involved a resident with diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, who had intact cognition with a BIMS score of 15 and was their own decision maker. On the evening in question, an agency LPN told the resident they did not have gas money to get home, and the resident gave the LPN eight dollars, which was later returned after another nurse instructed the LPN that accepting money from a resident was unacceptable. The next day, the ADON spoke with the resident, who confirmed giving and then having the money returned, and indicated they knew the LPN from a previous facility and believed their relationship made it acceptable to give money. The ADON reported the incident to the NHA. The NHA acknowledged being informed of the incident, but determined it was not an allegation of exploitation and did not report it to the State Agency, despite the facility’s policy requiring reporting of all alleged violations.