Elroy Health Services: Abuse Reporting Failure - WI
The incident happened on February 10, 2025. Federal inspectors arrived on March 3 and began asking questions. What they found was a facility that had watched a resident become visibly upset and weep, documented it in a progress note, collected staff accounts of what happened, and then concluded, through its administrator, that none of it met the threshold for a reportable incident.
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See the Derila PillowThe two residents at the center of the incident are identified in the inspection report only as R50 and R53. One of them, R53, was crying after the encounter. That detail appears in the facility's own progress note from the day it happened, and it came up again in staff interviews. It was not a disputed fact. The administrator knew about it.
Nine days after the incident, on February 19, a surveyor sat down with the Nursing Home Administrator, identified in the report as NHA A, and asked directly whether what happened between R50 and R53 could be considered resident-to-resident verbal abuse.
NHA A said no.
His explanation was that R50's outbursts were, in his understanding, directed more at staff members than at other residents. The surveyor pointed out that the progress note and the staff interviews both showed R53 was visibly upset and crying after the incident. The administrator's framing, that this was a staff-directed problem rather than a resident-to-resident one, did not account for what the documentation actually said.
The administrator told the surveyor he would use the CMS resident-to-resident altercation flowchart to guide his decision. He had used it. He had concluded the incident was not reportable.
The flowchart the administrator referenced asks a threshold question: did the resident act willfully? The document defines willful as deliberate, not inadvertent or accidental, and specifies that a resident whose involuntary movements cause them to accidentally strike another has not committed a willful act. If the answer to that question is no, the flowchart says not to report, but to document an immediate assessment, assess the situation, update the care plan, and intervene with the goal of preventing recurrence and keeping other residents safe.
The administrator landed on the "no" branch. He did not feel the incident rose to the level of a reportable event.
But the flowchart contains a second instruction that the facility did not follow. It states that use of the flowchart must provide for immediate reporting or the facility must clearly document the rationale for not reporting. Inspectors found no such documentation. The facility had not reported the incident to the state agency within the required timeframes, and it had not left a clear written record of why it chose not to.
What made the administrator's conclusion harder to defend was the nature of the incident itself. The report describes R50's behavior as yelling, though not directed at anyone specifically, just yelling in general. That characterization was part of how NHA A justified the non-report. But inspectors noted that several staff members had knowledge of the incident and that R53's distress was documented and confirmed. The facility's own records contradicted the administrator's framing.
Inspectors cited the facility for failing to recognize and report a resident-to-resident altercation despite staff awareness of what had happened. They also cited it for failing to recognize verbally aggressive behaviors and negative interactions with other residents as abuse. The deficiency was tagged with cross-references to F609, which covers mandatory reporting of alleged violations, and F744, which addresses the care of residents with mental or psychosocial adjustment difficulties.
The level of harm was listed as minimal harm or potential for actual harm. The number of residents affected was described as few.
Those classifications can make an incident sound minor. They should not obscure what the record shows: a resident cried. Staff saw it. The facility wrote it down. And then the person responsible for deciding whether to report it to the state looked at that record and decided the answer was no.
NHA A's reasoning rested on a behavioral pattern he believed he understood, that R50's aggression ran toward staff, not residents. That belief may have been informed by prior experience with R50. The inspection report does not say. What it does say is that on February 10, another resident was upset enough to cry, and that outcome did not change his analysis.
The CMS flowchart the administrator relied on was designed to give facilities a structured way to distinguish between accidental contact and deliberate behavior, and to ensure that even when facilities decide not to report, they explain why. The facility used the first function of that tool and skipped the second.
There is no indication in the inspection report that the facility updated R50's care plan after the incident, that it intervened to prevent a recurrence, or that it assessed what R53 needed in the aftermath. Those steps are listed as requirements on the same flowchart the administrator cited as his guide.
R53 does not have a name in the public record. The inspection report does not say how old she is, how long she has lived at Elroy Health Services, or whether she has family who knows what happened on February 10. It does not say whether anyone sat with her after she was done crying, or whether the staff who witnessed the incident told her that what happened to her would be looked into.
The administrator told the surveyor he did not feel it rose to the level of a reportable incident. The surveyor's notes suggest he felt otherwise. The deficiency citation suggests the same.
What the inspection report cannot say is what R53 understood about why no one reported what happened to her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elroy Health Services from 2025-03-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
ELROY HEALTH SERVICES in ELROY, WI was cited for abuse-related violations during a health inspection on March 3, 2025.
The incident happened on February 10, 2025.
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.