F0609

D

Failure to Report and Investigate Alleged Abuse, Resident Altercation, and Staff Identity Fraud

Edgerton, Wisconsin Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report and thoroughly investigate alleged abuse, neglect, exploitation, or mistreatment, and to notify the State Survey Agency and other required authorities as outlined in its own abuse policy. The facility’s written policy, dated 2025, requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, including identifying and interviewing all involved persons and documenting the investigation. The policy also requires reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes: within 2 hours if the allegation involves abuse or serious bodily injury, and within 24 hours if it does not. Despite these requirements, surveyors found three separate incidents involving three residents and one staff member where the facility did not follow its procedures for investigation and reporting.

In the first incident, a resident with paranoid schizophrenia and severe dementia (R1) allegedly slapped another resident with severe dementia and Down syndrome (R5) on 2/16/26. A CNA (CNA D) was informed by another resident (R12) that R1 had slapped R5’s face; CNA D separated the residents and reported the incident to an LPN (LPN C). LPN C assessed R5 for red marks, reported the incident to the ADON, and informed a family member, but did not complete further assessment, did not document the incident, and did not conduct or initiate a formal investigation. The Nursing Home Administrator (NHA A) later acknowledged that she had been informed that R1 slapped R5, but there was no documentation, no interviews of the CNA or nurse who reported the incident, no follow-up with R1 and R5, and no broader inquiry into other residents’ safety. NHA A stated that a resident-to-resident altercation should be investigated and that this incident could have been potentially reportable to the state, but no investigation or report was completed.

In the second incident, surveyors investigated a complaint that an agency CNA was working under a false name. The administrator reported that police came to the facility on 3/4/26 to arrest a CNA identified as CNA T for potential credit card fraud, and it was then discovered that the individual working as CNA T was actually another person (CNA S) using her mother’s identity to obtain work through the staffing agency. The administrator stated that the facility relied on the staffing agency’s hiring and background checks and did not request identification from agency staff upon orientation, and that no changes had been made to the process for verifying agency staff identity. When asked, the administrator acknowledged that she did not report this situation to the State Survey Agency, explaining that she believed it was an active police investigation related to credit card fraud rather than the false identity used to work at the facility. As of exit, the facility could not provide additional information explaining why it did not report the suspicion of a crime when it became aware that an agency CNA was working under false identification.

In the third incident, a CNA (CNA Q) reported that another staff member forced a resident (R6) out of bed on 2/21/26 despite the resident’s expressed wish to remain in bed due to pain and to wait for morning medications. According to CNA Q, she informed another CNA that R6 did not want to get up, and that CNA then entered the room, yelled at R6, forced him out of bed, and called him racist. CNA Q stated she felt this was abusive and reported it to the nurse, who then reported it to the administrator. The facility conducted a thorough internal investigation into this allegation; however, the State Agency had no record of the incident being reported. In an interview, the administrator stated that she believed the allegation sounded like abuse and that she should have reported it to the state agency, but by the time she realized it should have been reported, the reporting timeframe had passed and she decided not to report it at all. Across all three examples, the facility did not ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment were immediately reported and investigated in accordance with its policy and state and federal requirements.