MUSCODA, WI - State inspectors documented systematic failures in abuse reporting and investigation protocols at Riverdale Health Care Center following a July 2024 complaint inspection that revealed facility administrators failed to properly handle multiple serious allegations involving vulnerable residents with cognitive impairments.
Pattern of Inadequate Abuse Reporting Emerges
The inspection revealed multiple instances where facility leadership failed to follow mandatory reporting requirements and investigation protocols when residents reported potential abuse or mistreatment. These failures affected several cognitively impaired residents who depended on staff protection and proper administrative oversight.
The most concerning pattern involved the facility's inconsistent approach to evaluating and reporting allegations. In some cases, administrators failed to contact law enforcement or state agencies when required. In others, mandatory reporting timelines were not met. The inspection also uncovered instances where allegations were verbally communicated to leadership but never formally documented or investigated.
Delayed Response to Resident's Reports of Rough Treatment
One of the most serious violations involved a resident with Type 2 Diabetes, stage 4 chronic kidney disease, metabolic encephalopathy, and congestive heart failure. The resident, identified in records as R2, had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15, indicating significant mental limitations that made him particularly vulnerable.
On June 29, 2024, R2 reported that certified nursing assistants "were rough during the night, during cares." When interviewed, he stated staff members had "plopped him back and forth" and "were rougher than they should have been." He pointed to his left shoulder and said his arm was "hurting like a bh," adding "it wasn't nice, it wasn't fun."
Multiple staff members documented the resident's complaints. One nursing assistant reported that R2 said "the girls just picked him up and threw him in bed and rolled him." Another staff member documented that when answering the call light, R2 "almost immediately" reported being "pulled around every which way in bed" due to his left shoulder pain.
Despite these clear allegations of rough handling reported on June 29, facility leadership did not file an initial allegation report with the state agency on that date. According to facility policy, allegations must be reported immediately but no later than two hours if events involve abuse or result in serious bodily injury, or within 24 hours if they don't result in serious injury.
The situation escalated when R2 was sent to the hospital for hypoglycemia, where imaging revealed a fracture of the shaft of the humerus in his left arm. Only after receiving x-ray results showing the fracture on July 3, 2024—four days after the initial complaint—did the Director of Nursing report the allegation to the state agency.
The medical significance of this delay cannot be understated. A humerus fracture causes severe pain and requires immediate medical evaluation to prevent complications. The humerus is the long bone in the upper arm, and fractures typically result from significant force or, in vulnerable patients, from pathological weakness. When a cognitively impaired resident reports pain and rough handling, immediate investigation and medical assessment are critical to determine the cause of injury and prevent further harm.
The facility's investigation concluded the fracture was "most likely spontaneous and pathological" with possible underlying cancer. However, the delayed reporting meant crucial time was lost in documenting the circumstances surrounding the injury and protecting the resident from potential ongoing rough handling.
During the state inspection, the Director of Nursing acknowledged the failure: "These are allegations of abuse and should be reported immediately to the state agency within 2 hours or within 24 hours. She was responsible for reporting to the state agency, and she did not do it until x ray results showed a fracture on July 3, 2024. She should have filed an initial allegation report on June 29, 2024."
Notably, the staff members alleged to have been rough with the resident were not suspended pending investigation and continued working with R2 without additional supervision—another violation of protection protocols.
Rape Allegation Not Reported to Authorities
In a separate incident, another resident identified as R7 informed staff on June 27, 2024, at 10:00 AM that he had been "raped by two black women." This allegation required immediate action under both state and federal regulations.
The facility never contacted law enforcement about the rape allegation. The facility also failed to report the allegation to the state agency as required. When inspectors questioned the Nursing Home Administrator about these failures, she stated she had consulted with corporate staff who advised her that law enforcement did not need to be called and the allegation did not need to be reported to the state agency. Instead, she was instructed to "put the information in a soft file."
This represented a fundamental misunderstanding of mandatory reporting requirements. Sexual assault allegations in nursing homes trigger specific legal obligations regardless of the victim's cognitive status or the perceived credibility of the report. Law enforcement must be notified to conduct a criminal investigation, and state regulatory agencies must be informed to ensure resident protection.
During the inspection, the administrator acknowledged the error, stating that "law enforcement should have been contacted when R7 made the allegation and the allegation should have been reported to the State Agency."
The failure to properly investigate this allegation meant no formal interviews were conducted with potential witnesses, no review of facility access records occurred, and no assessment was made of whether the resident faced ongoing danger. Medical forensic examination, which is time-sensitive in sexual assault cases, was never considered.
Unreported and Uninvestigated Verbal Abuse
The inspection also revealed that allegations of psychological abuse were verbally reported to facility leadership but never formally documented or investigated. A resident identified as R13, admitted with dementia and history of stroke, had a Brief Interview for Mental Status score of 7 out of 15, indicating severe cognitive impairment.
The current Nursing Home Administrator, who previously worked as the facility's social worker, observed an agency certified nursing assistant "egging on" the resident. She described witnessing the staff member deliberately provoking R13, saying things like "Are you mad again?" with the intent of upsetting him. The administrator stated she would "consider this abuse" because "it falls under the definition of humiliation."
The resident's family also reported the same concern about this staff member's treatment of their loved one. These observations and family reports were verbally communicated to the previous Nursing Home Administrator but were never documented, investigated, or used to educate staff on preventing similar incidents.
According to facility policy, psychological abuse and verbal abuse must be investigated with the same thoroughness as physical abuse. The policy specifically identifies "psychological abuse of a resident observed" and "verbal abuse of a resident overheard" as situations requiring immediate investigation.
The agency staff member continued working at the facility until May 30, 2024, when the facility finally made him "Do Not Return."* However, no documentation exists explaining the reason for this action, and no formal investigation was ever conducted into the observed and reported psychological abuse.
When inspectors interviewed R13, he stated "the real bad ones are gone" and confirmed that the staff member "didn't treat me bad at first, but then it got bad," adding that the worker "would call me names." Due to his severe cognitive impairment, R13 had difficulty remembering specific events, which underscores why administrative documentation and investigation are essential for protecting vulnerable residents who cannot reliably advocate for themselves.
Medical and Regulatory Context
Nursing home residents with cognitive impairment face heightened vulnerability to abuse and mistreatment. Dementia, stroke, metabolic encephalopathy, and other conditions affecting mental status impair a person's ability to report abuse, remember incidents consistently, or advocate for their own safety. Federal regulations recognize this vulnerability and establish strict requirements for how facilities must respond to any allegation.
The investigation requirements exist because cognitively impaired individuals may not be considered reliable witnesses in their own defense, yet their reports often contain truth even when details are confused. Immediate documentation and investigation preserve evidence, identify patterns, and enable protective interventions before additional harm occurs.
Mandatory reporting serves multiple protective functions. It ensures oversight by agencies with investigative authority, triggers criminal investigations when appropriate, and creates accountability for facility responses. Reporting timelines are specifically calibrated to the severity of alleged harm—two hours for serious bodily injury or abuse allegations, 24 hours for other incidents.
The failure to investigate thoroughly means facilities cannot identify systemic problems contributing to abuse. Without analyzing why incidents occurred and implementing changes, the same conditions persist and additional residents remain at risk. Staff training following substantiated abuse is not punitive—it is educational, designed to help all employees recognize warning signs and understand proper care techniques.
Additional Issues Identified
Beyond the major abuse reporting failures, inspectors documented that a five-day self-report following a physical altercation between two residents on May 4, 2024, was not submitted timely. The completed report was due on May 10, 2024, but was not properly submitted via the required Misconduct Incident Reporting system until May 30, 2024—20 days late. While the facility took appropriate actions at the time of the incident, the delayed reporting violated state requirements for timely notification.
The inspection findings reveal systematic breakdowns in the facility's abuse prevention and reporting systems. Multiple administrators failed to recognize reportable allegations, understand mandatory timelines, or complete thorough investigations. Corporate consultation provided incorrect guidance about reporting requirements. The facility's processes for tracking and following up on allegations were inadequate to ensure resident protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bedrock Hcs At Riverdale LLC from 2024-07-10 including all violations, facility responses, and corrective action plans.
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