F0610

D

Failure to Conduct and Document Comprehensive Abuse/Neglect Investigations

Hales Corners, Wisconsin Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct and document a thorough investigation into an allegation of neglect for one resident and to fully evaluate a CNA’s history of concerning interactions with residents during an abuse/neglect investigation. One resident was admitted with diagnoses including myocardial infarction, congestive heart failure, and cellulitis. After a family member reported concern about swelling in the resident’s feet, nursing staff assessed the resident, noted bilateral leg and foot swelling, and recommended emergency room evaluation, after which the resident was admitted to the hospital for acute exacerbation of chronic heart failure. The family member later alleged neglect, and a grievance was filed with the assistance of the social worker.

Despite this allegation and the resident’s documented cognitive intactness (BIMS score of 13/15), the facility’s investigation records did not show that other residents were interviewed about neglect concerns or that staff were educated on abuse and neglect policies as part of a comprehensive investigation. The Administrator stated she did not consider it necessary to interview other residents because she viewed the case as unique and without similar concerns among other residents, and she did not consider staff training necessary because she believed there was no actual neglect or abuse in this case. This approach was inconsistent with the facility’s written Abuse, Neglect and Exploitation policy, which requires immediate investigation procedures including identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.

A separate incident involved another resident with vaginal cancer who alleged that a CNA entered her room, came close to her, and stated, “Be sure you know who you accuse,” which the resident reported as intimidating. The facility’s investigation concluded the allegation was unsubstantiated and did not include documentation of abuse-related education or other training for the CNA or staff. Review of the CNA’s personnel file showed multiple prior resident complaints, including telling a resident to be more independent and not ensuring needs were met after providing supplies, using an authoritative tone, yelling at another resident for being wet, making embarrassing comments about incontinence, insisting on clothing choices against resident preference, repeating completed care tasks, and leaving a resident on the toilet long enough to play two games on her phone. Although the CNA had been placed on performance improvement plans for customer service, respectful communication, and resident rights, the Administrator reported she was unaware of all documented concerns and believed she could not use prior personnel records after a change in facility ownership. The facility’s investigation into the later abuse allegation did not reflect a review and integration of this history as part of a comprehensive investigation, contrary to the facility’s policy requiring complete and thorough documentation and focus on determining whether abuse, neglect, or mistreatment occurred.