F0610

D

Failure to Thoroughly Investigate and Manage Allegation of Staff Sexual Misconduct

Superior, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to thoroughly investigate an allegation of sexual misconduct, maintain documentation of a complete investigation, and prevent further potential abuse, neglect, exploitation, or mistreatment during the investigation for one resident. The resident had diagnoses including pneumonia, stroke, Lewy Body Dementia, hallucinations, amnesia, and cognitive communication deficit, and was assessed as cognitively intact with a BIMS score of 14/15, being independent with eating and bed mobility and requiring supervision for transfers and toileting. The facility’s abuse-prevention policy required the DON or designee to contact the resident’s physician when an allegation arose and to immediately remove any accused staff member from the facility and schedule pending the outcome of the investigation, as well as to provide ongoing staff training on abuse, neglect, exploitation, and related topics.

Surveyors reviewed the facility’s grievance records and the investigation of an incident in which the resident accused an RN of offering sex. Review of the investigation and the resident’s electronic health record showed no evidence that the resident’s physician was notified of the allegation, no evidence that the accused RN was suspended or removed from the facility during the investigation, and no evidence of ongoing abuse-related education provided to staff following the incident. During interview, the DON confirmed that the physician had not been updated, that the RN remained punched in and in the building during the investigation, and that there was no documentation to prove the RN had no resident contact during that time. The DON also confirmed that staff were not re-educated regarding abuse/misconduct policies and procedures after the allegation.