F0609

D

Failure to Report and Adequately Investigate Alleged Abuse and Injury of Unknown Origin

Racine, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and thoroughly investigate alleged abuse and an injury of unknown origin, and to report these incidents to the State Agency as required by facility policy. One incident occurred when a confused resident entered another resident’s room; the resident in the room told the other to leave, but the intruding resident grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. A nursing progress note documented this resident‑to‑resident incident and that staff intervened, separated the residents, and notified leadership. However, there was no corresponding facility‑reported incident or investigation provided for this event, and the current NHA, who was not employed at the time, was unable to locate any prior investigation related to the incident.

A second deficiency relates to an abrasion to the head identified as an injury of unknown origin for the same resident who had entered the other resident’s room. The facility produced an investigation document noting a skin abrasion and marks of unknown origin, with references to fall protocol review, staff statements, skin assessment, notifications, and neuro checks, but the factual discoveries section was left blank. The CNA and LPN who first identified and documented the injury on a shower sheet and in a progress note were not interviewed as part of the investigation. The DON acknowledged not knowing the source of the injury and could not explain why the investigation began three days after the injury was found, despite the facility’s abuse policy requiring immediate reporting and investigation of alleged abuse and injuries of unknown origin, including notification of the State Agency.