Middleton Village Nursing And Rehab

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 reportable incidents involving 1 of 3 residents reviewed for abuse (Resident R1).An allegation of abuse was made involving facility staff inappropriately touching Resident R1, this was not reported to

the State Agency.Evidenced by:The facility's abuse policy states, The facility will have written procedures that include: Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a.) Immediately, but not later than 2 hours

after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b.) not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Resident R1 was admitted to the facility on [DATE REDACTED].On 9/23/25, the facility became aware of an allegation of sexual abuse regarding Resident R1. A family member of Resident R1 reported to NHA A (Nursing Home Administrator) that a CNA had inappropriately touched Resident R1's private area during routine care. The facility conducted an investigation including interviews and education with staff regarding the facility's abuse policy, which concluded on 9/30/25. As of 10/8/25, a report was still not submitted to the state agency.On 10/8/25 at 2:50 PM, Surveyor interviewed NHA A who stated that that the incident should have been submitted to the state on 9/23/25. NHA A stated that she had received education on the abuse policy and indicated that she should have then submitted a report to the state regarding the 9/23/25 allegation, given that the education of the abuse policy had included timely reporting to the state agency.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Middleton Village Nursing and Rehab

6201 Elmwood Ave Middleton, WI 53562

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not suspended or removed from resident care. When the grievance became elevated to include a sexual nature on 9/23/25, the facility did not conduct any additional interviews or ask any additional questions of staff or residents. On 10/8/25 at 2:50 PM, Surveyor interviewed NHA A who stated that the incident should have been submitted to the state on 9/23/25 when the grievance was elevated. NHA A stated that she had received education on the abuse policy and indicated that she should have then submitted a report to the state regarding the 9/23/25 allegation, including findings report, given that the education of the abuse policy had included timely reporting to the state agency.

Event ID:

Facility ID:

If continuation sheet