Alden Meadow Park: Pain Management Failures - WI
The resident, identified as R33 in inspection records, suffers from multiple painful conditions including rheumatoid arthritis, bilateral knee osteoarthritis, and ankylosing spondylitis of the spine. She told inspectors on January 28 that she experiences sharp pains in her feet and toes, and arthritis pain in her legs that sometimes reaches "10 out of 10."
"She tells the nurse that she wants to see the nurse about her pain, but the nurses never come in and ask her about her pain," inspectors documented. "R33 stated that this pain has been going on for over a month, and she feels ignored by staff."
The next morning, inspectors watched Licensed Practical Nurse C administer morning medications to R33. The nurse entered the room, handed R33 her medication cup, and waited in the doorway while the resident took her pills.
When asked if she had assessed R33 for pain, LPN C said she had not completed a pain assessment. She had already marked zero for pain in the electronic health record.
Only after the inspector's questioning did LPN C return to R33's room and use a whiteboard to communicate with the deaf resident. R33 indicated her legs "hurt bad today" and rated her pain 9 out of 10. LPN C had already given R33 her scheduled acetaminophen.
The facility's own policy requires staff to assess residents for pain "upon admission, re-admission, and annually" and to "assess for chronic pain or persistent pain when the symptoms present themselves." Care plans must include "both pharmacological and complementary interventions."
R33's care plan, initiated in July 2022, specifically addresses her arthritis pain. It instructs staff to "assess pain every shift" and "monitor for non-verbal indicators of pain daily with care tasks and activities." The plan also calls for offering pain medication before activities and positioning the resident for comfort.
But staff interviews revealed widespread failures to follow these protocols.
Certified Nursing Assistant O told inspectors that R33 "has pain when they get her up in the morning" and "will scrunch up her face in pain and ask them to move slow because of her pain." When asked if she notifies nurses about R33's obvious distress, CNA O said no. "They just move slower and give R33 time to rest."
When asked if she should alert nurses when R33 exhibits pain, CNA O acknowledged: "Yes, she should probably get the nurse."
The documentation tells a different story than what staff observed. R33's medication administration records show pain evaluations consistently documented as 1's and 0's. In December 2024, only six evaluations were marked as 1, with the rest marked as 0. In January 2025, only ten evaluations showed a pain level of 1.
Director of Nursing B acknowledged the disconnect when confronted by inspectors. She said "sometimes R33 will tell you she has 10 out of 10 pain, but when the nurses do a pain assessment she will tell them 0 out of 10."
But DON B also revealed a more troubling pattern. She told inspectors that the nurse practitioner "tends to just copy and paste without reading the resident's chart, and that is a process they need to work on."
Medical records support this concern. Progress notes dated October 31, November 8, November 12, and November 21, 2024 contain identical language copied word-for-word from an October 28 note. None included "personalized or new interventions to address resident's pain."
The most recent pain management evaluation, completed January 16, documented R33's pain level as 0 and answered "No" when asked if the resident had any diagnosis that would cause pain. This directly contradicted an evaluation from October 21 that correctly identified her rheumatoid arthritis, spinal spondylitis, and knee osteoarthritis as pain-causing conditions.
Assistant Director of Nursing I admitted the error when shown the assessment by inspectors. She confirmed that R33 "does have a diagnosis that would indicate pain" and that rheumatoid arthritis "would indicate pain."
Physical Therapy Assistant O told inspectors that R33 "does have knee pain and gets cortisone shots that does help with the pain and her mobility." But multiple staff members said they weren't walking with R33 because of her pain levels.
CNA H explained that "R33's pain has been so bad in her knees lately that the staff have not been walking with her much." Yet R33 told inspectors that walking helps her pain and that therapy wants her to walk.
"R33 said she felt like the staff did not want to walk with her because they didn't have time," inspectors noted.
When asked if anyone had assessed her pain on January 29, R33 replied: "No, that is part of the problem." She told inspectors no one had offered to walk with her that day, despite her care plan calling for positioning and repositioning for comfort.
R33's family member painted a picture of systemic dismissal. The relative told inspectors that facility staff say R33 "is getting old and imagining things but that R33's mind is actually very sharp." The family member said staff "look at R33 and her age and that she is deaf and they don't treat her like she knows what she is talking about."
R33 has a Brief Interview for Mental Status score of 14, indicating she is cognitively intact.
The family member told inspectors they believe "the facility could be doing more to address R33's pain."
R33's medical conditions require ongoing management. Her rheumatoid arthritis is described by her family as "bone on bone, and very painful." She receives cortisone injections every three months, but the family member explained that "when they wear off the pain is really bad."
Despite having multiple pain medications available, including acetaminophen, Voltaren gel for her hands and knees, lidocaine patches for her back, and gabapentin for nerve pain, staff failed to properly assess when these interventions were needed.
The facility's own progress notes from January acknowledge the problem. A January 9 nursing note states that R33 "has chronic joint pain and takes scheduled Tylenol for this which has been effective." But an January 11 note admits she "at times needs more assistance with ADLs" due to her arthritis.
R33 told inspectors she has been telling nurses about her foot and toe pain for over a month, but "they don't believe her."
Federal inspectors concluded that Alden Meadow Park failed to adequately assess R33's pain or provide non-pharmacologic interventions to treat her suffering. The facility's own policies required comprehensive pain management that never materialized for this cognitively intact resident with multiple painful conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Meadow Park Hcc from 2025-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
ALDEN MEADOW PARK HCC in CLINTON, WI was cited for violations during a health inspection on January 30, 2025.
The nurse entered the room, handed R33 her medication cup, and waited in the doorway while the resident took her pills.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at ALDEN MEADOW PARK HCC?
- The nurse entered the room, handed R33 her medication cup, and waited in the doorway while the resident took her pills.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CLINTON, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ALDEN MEADOW PARK HCC or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525508.
- Has this facility had violations before?
- To check ALDEN MEADOW PARK HCC's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.