Elroy Health Services: COVID Outbreak Mismanagement - WI
The scene at Elroy Health Services in February revealed a breakdown in infection control that state inspectors found affected all 68 residents. Staff members providing direct care didn't know about their own outbreak. Others wore masks below their noses or chins while speaking with visitors. Workers returned to their jobs within 24 hours of vomiting and diarrhea.
Dietary Aide L told an inspector on February 16 that he "was not aware the facility was in outbreak and that is why he had not been wearing a mask earlier." The surveyor had observed him delivering a drink cart through the hallway that morning without any face covering.
During the same interview, the dietary aide wore his mask below his nose. When the inspector asked if he was wearing it correctly, he admitted he was not.
The facility had posted a sign at its front entrance stating "We are currently experiencing a COVID outbreak" and requiring masks "at all times during your visit." But that message apparently never reached the staff caring for residents inside.
Certified Nursing Assistant O sat in the facility's center hub without a mask that same morning. When interviewed later, she acknowledged "she should have been wearing a mask earlier but was not."
Licensed Practical Nurse N told an inspector the facility wasn't in outbreak status at all. "Staff were wearing mask as a precaution," she said, contradicting the Director of Nursing who confirmed the outbreak had been ongoing since February 4.
The confusion extended beyond basic awareness. Registered Nurse P stood in a hallway on February 17 with her mask below her chin while talking to visitors. She told the inspector she believed only one staff member had tested positive for COVID and wasn't sure if the facility remained in outbreak status.
A pest control contractor walked through the dining room where residents were eating breakfast, then spoke with the administrator in the facility's center hub, all without wearing a mask. He told inspectors no staff member had informed him about the outbreak or asked him to wear protective equipment, despite the warning sign at the entrance.
The facility's infection control failures stretched back months. Inspectors found the nursing home had prematurely ended a previous COVID outbreak in November 2024, closing it after just 15 days instead of the required 28-day period Wisconsin health officials specify for respiratory outbreaks.
That October outbreak began on October 2 and should have continued until at least two incubation periods passed without new cases. But the facility discontinued universal masking on November 17, even though a resident had tested positive for COVID on November 2 — just 15 days earlier.
Staff surveillance records revealed a pattern of incomplete documentation and workers returning too early from illness. The facility's Infection Preventionist acknowledged during interviews that the tracking was inadequate.
Hospitality Aide FF called in sick December 7 with headache, nausea and vomiting, then returned to work December 8 — exactly 24 hours later. The aide called in sick again December 20 with vomiting and returned December 21, another 24-hour turnaround.
Certified Nursing Assistant GG reported nausea, vomiting and diarrhea December 10 and returned December 11. The facility's own infection preventionist later told inspectors that both FF and GG "returned to work too early."
The surveillance logs contained multiple gaps. Maintenance worker MN II called in January 7 with no symptoms documented at all. Several staff members had no recorded date when their symptoms resolved, making it impossible to determine appropriate return-to-work timing.
Unit Clerk J called in December 16 with muscle pain, headache and sore throat but received no COVID testing, despite the facility's policy requiring tests for staff with COVID-like symptoms. Registered Nurse I reported similar symptoms January 2 along with diarrhea, also without documented testing.
The kitchen presented additional safety concerns during the February inspection. Dietary Aide L worked without a beard restraint, violating the facility's food service policy requiring hair restraints "to prevent hair from contacting exposed food."
Garbage cans near food preparation areas lacked lids. Inspectors observed a yellow substance spilled in the walk-in refrigerator that the Dietary Manager identified as likely eggs.
These violations occurred while the facility maintained its outbreak status, compounding risks to residents already vulnerable during an active COVID transmission period.
The Administrator acknowledged understanding the problems when interviewed February 19, stating he "would expect staff to wear a beard restraint when in the kitchen and when handling food" and recognizing issues with the spilled food and uncovered garbage containers.
But the damage was already evident. During an active outbreak requiring heightened precautions, workers moved freely through resident areas without masks, unaware of the very outbreak they were supposed to be controlling.
The facility's infection control program promised "oversight" and "leadership" in preventing disease transmission. Instead, inspectors found a system where staff didn't know basic information about their own workplace safety status while caring for 68 vulnerable residents during an ongoing outbreak.
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: 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 20, 2026 · Our methodology
ELROY HEALTH SERVICES in ELROY, WI was cited for violations during a health inspection on March 3, 2025.
The scene at Elroy Health Services in February revealed a breakdown in infection control that state inspectors found affected all 68 residents.
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.