Elroy Health Services: Dementia Care Plan Failures - WI
Federal inspectors documented the situation at Elroy Health Services during a survey completed in early March 2025. The resident, identified in inspection records only as R50, had claimed a room at the facility known as the bird room and treated it as her personal office. When other residents came near things she believed were hers, she screamed at them. When staff tried to intervene, she either ignored them entirely or escalated into louder outbursts. When a volunteer arrived to lead bible study in the bird room, R50 screamed and cussed at her too.
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A registered nurse interviewed by inspectors said R50 targets certain residents, particularly if she believes they are taking her things. The nurse said R50 has chased family members out of the room by screaming at them. She also refuses all nursing care.
Asked what interventions were in place, the nurse said the staff just gives R50 space, because she is not agreeable to anything. The more they try to talk to her, the nurse explained, the more R50 either ignores them or explodes. The nurse told inspectors this had been going on for months.
There was no care plan.
R50's dementia diagnosis was not documented on her care plan. Her behaviors were not listed. No triggers were identified. No interventions were recorded. A new employee walking onto that unit would have had nothing to tell them who this woman was, what set her off, or what might calm her down.
The Director of Nursing, identified in the report as DON B, confirmed all of this when inspectors sat down with him on February 19. He acknowledged that behaviors should be listed on a care plan. He acknowledged that a dementia diagnosis should be there too, along with triggers and interventions. He described R50's situation clearly: she acts like the bird room is her office, she knows it isn't but feels entitled to use it that way, she becomes very argumentative with staff and other residents, though she has never been physically aggressive.
Then he acknowledged that without any of that in the care plan, it would be hard for a new employee to know how to de-escalate her.
He said it was his expectation that R50's dementia, her behaviors, and her interventions should have been on her care plan all along.
They weren't.
The inspection report notes that the facility failed to assess, develop, and implement an individualized care plan to meet R50's dementia care needs. The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
What that language doesn't fully capture is the texture of what inspectors found: a woman whose illness had gone unaddressed in any formal way for months, while the people around her, other residents trying to watch television or attend a religious activity, navigated her outbursts without any staff equipped to help. The registered nurse summed up the facility's approach plainly. They gave her space. That was it. That was the plan.
Other residents, the nurse told inspectors, are intimidated by R50. Activities that once took place in the bird room were relocated because of her. The volunteer who came to offer bible study left having been screamed and cussed at, with no indication that anyone at the facility had a structured response waiting.
DON B told inspectors he expected better. The care plan still wasn't there.
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.
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Last verified: November 13, 2026 · Our methodology
ELROY HEALTH SERVICES in ELROY, WI was cited for violations during a health inspection on March 3, 2025.
Federal inspectors documented the situation at Elroy Health Services during a survey completed in early March 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.