Lakeland Health Care Ctr: Staff Held Resident Down - WI
The incident at Lakeland Health Care Center came to light during a complaint inspection completed September 2, 2025. Federal inspectors cited the facility for actual harm under the tag governing care of residents with dementia, one of the more serious harm designations available to surveyors.
The resident, identified in inspection records only as R1, lives in the facility's memory care unit and has a documented history of dementia and poor impulse control. R1 may hit or strike out at staff or peers during care. Inspectors found that behaviors were documented as far back as May 2025. No behavior care plan was created. R1's physician was not notified.
The behaviors continued into July. Still no care plan. Still no call to the doctor.
By August, staff sent a written communication note to R1's physician on August 9 raising the possibility that the behaviors might be a symptom of a urinary tract infection. The physician did not acknowledge the note that day. Or the next. The facility did not follow up either time.
The behaviors kept going. And then, at some point in August, a registered nurse identified in the report as RN-D yelled at R1 and held R1's shoulders down. The inspection report states plainly that this made R1 afraid.
It was only on August 15, after more than three months of documented challenging and aggressive behaviors, that facility staff finally entered a behavior care plan into the record. The plan instructed staff to analyze the times, places, and triggers of R1's behaviors, to assess for sensory deficits, to anticipate needs like food, thirst, toileting, and pain, and to walk calmly away if a resident became aggressive and approach again later.
That guidance, the kind that might have shaped how RN-D responded, did not exist when the nurse pinned R1 down.
On August 27, the surveyor sat down with Nursing Home Administrator A and Director of Nursing B and walked through the timeline. The administrator's response was that R1's behaviors were more consistent with sundowning, and that R1 lives in the memory care unit, where staff know what to do because of their training.
The administrator acknowledged understanding the concern about the missing care plan. But the explanation offered was that the unit's trained staff already knew how to handle it.
What the record shows is that a trained staff member yelled at a frightened resident and held that resident down by the shoulders.
The administrator did not provide additional information to the surveyor. The inspection report notes that no additional information was provided.
A behavior care plan is not a bureaucratic formality. For a person with dementia who cannot reliably communicate distress, cannot always understand why someone is touching them, and cannot advocate for adjustments to their own care, a written plan is often the only mechanism that carries institutional knowledge from one shift to the next, from one caregiver to another. Without it, each interaction depends entirely on whoever happens to be in the room and whatever that person decides to do in the moment.
RN-D was in the room. RN-D decided to yell and to hold.
The facility's memory care unit presumably cycles through staff across three shifts, seven days a week. The administrator's confidence that training alone was sufficient to protect R1 did not account for the nurse who was there that morning and responded the way she did.
R1 was left afraid.
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.
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: August 5, 2026 · Our methodology
LAKELAND HEALTH CARE CTR in ELKHORN, WI was cited for violations during a health inspection on September 2, 2025.
The incident at Lakeland Health Care Center came to light during a complaint inspection completed September 2, 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.