Lakeland Health Care Ctr: Abuse Violation - Elkhorn, WI
The incident was serious enough to trigger a finding of immediate jeopardy, the most severe classification federal inspectors can assign, indicating a reasonable likelihood of serious harm. The facility, at 1922 County Road NN in Elkhorn, serves residents in a dedicated memory care unit.
The resident, identified in inspection records only as R1, had documented behavioral episodes tied to dementia as far back as May 2025. Dementia can cause a person to strike out, resist care, or become agitated in ways that are unpredictable and difficult to manage. None of that was new information at Lakeland. What was missing, for more than three months, was any formal plan to guide staff through it.
No behavior care plan. No notification to R1's physician. Just staff on a memory care unit left to handle an increasingly distressed resident on their own.
The nurse involved, identified as RN-D, was described in the report as attempting to keep R1 safe when the incident occurred. That framing matters: the investigation ultimately substantiated the abuse, but it also pointed to something the report made plain. A staff member, untrained in how to specifically manage this resident's escalating behaviors, reached a breaking point. The result was a vulnerable person being held down and yelled at in a place they were supposed to be protected.
The behavior care plan that should have existed in May was not initiated until August 15, 2025, more than three months after R1's behaviors were first documented. It outlined what any competent dementia care plan would include: analyzing the times and circumstances of behavioral episodes, anticipating needs like food, thirst, and toileting, providing calm verbal and physical cues, and, critically, walking away if a resident became aggressive and approaching again later. That last intervention, walking calmly away, is precisely what did not happen when RN-D held R1's shoulders down.
The facility's administrator, identified as NHA-A, acknowledged the missing care plan when confronted by the surveyor on August 27. But the explanation offered was telling. NHA-A said R1's behaviors were "more sundowning" and noted that R1 lived in the memory care unit. Then came the line that captured the problem entirely: NHA-A said staff on the unit "know what to do because of their training."
General training is not the same as a specific plan for a specific person. The inspection report made that distinction explicit.
What the record also showed was a facility that had a chance to catch this before it became abuse and didn't take it. On August 9, 2025, a staff member sent a communication note to R1's doctor raising the possibility that R1's worsening behaviors might be a symptom of a urinary tract infection, a common and treatable cause of sudden behavioral changes in elderly residents with dementia. The doctor did not respond. August 9 passed. August 10 passed. Nobody at Lakeland followed up. R1's behaviors continued.
Then came the incident with RN-D.
The immediate jeopardy finding was issued under citation F600, which covers freedom from abuse. Inspectors determined the facility's failure to protect R1 from physical and verbal abuse created a reasonable likelihood of serious harm, including psychosocial harm. The finding was classified as past non-compliance, meaning the jeopardy had already been removed by the time inspectors completed their review.
The removal happened on August 11, the same day police were notified. Staff were educated on abuse and residents' rights that day. The facility held an all-staff meeting on August 18 that added more abuse training alongside sessions on burnout and stress management. Staff who didn't attend had an online version available by August 25. Audits began on August 11, with staff checking in with five residents per day and five staff members per day, looking for concerns related to abuse, misconduct, and stress. Grievance reviews started the same day. The immediate jeopardy was formally corrected on August 25.
That sequence of events is worth sitting with. The facility moved fast once inspectors got involved. Police were called. Training was deployed. Audits were launched. All of it within days of the incident becoming a matter of formal record.
None of it happened in May, when R1's behaviors first appeared in documentation. None of it happened in June or July. The doctor wasn't looped in. A care plan wasn't written. And when a communication note finally went out on August 9 flagging the possibility of a medical cause for the behaviors, no one followed up when the doctor didn't respond.
The inspection report noted that surveyor observed the behavior care plan had been initiated on August 15, "after over 3 months of challenging behaviors." That phrase, buried in regulatory language, is the center of this story. Three months of a dementia patient showing signs of distress, and the facility's formal response was to assume that general staff training was sufficient.
R1's care plan, once it finally existed, described the resident as having "potential to be physically aggressive related to dementia and poor impulse control as result of impaired cognition." It noted that R1 "may hit or strike out at staff or peers during cares." That language did not appear for the first time in August. The behaviors it described had been present since May.
The abuse finding was substantiated even though the nurse was described as trying to keep R1 safe. That is not a contradiction. A person can be acting with good intentions and still cause harm. A staff member can be overwhelmed, undertrained for a specific situation, and still be held accountable for yelling at and physically restraining a frightened resident with dementia. The investigation found both things to be true at once.
What the report does not say is what R1 experienced in the aftermath, or whether R1's physician ever responded to the August 9 note, or whether the possible UTI was ever evaluated. The record ends where the regulatory process ends.
R1 was afraid. That much the report states directly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeland Health Care Ctr from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LAKELAND HEALTH CARE CTR in ELKHORN, WI was cited for abuse-related violations during a health inspection on September 2, 2025.
The facility, at 1922 County Road NN in Elkhorn, serves residents in a dedicated memory care unit.
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.