Juliette Manor: Abuse Reporting Failures Documented - WI

The inspection, completed September 10, 2025, stemmed from a complaint. What surveyors found was a facility that had cycled through multiple rounds of staff education on abuse reporting and resident rights over the course of two weeks, and still could not produce a single signed acknowledgment from the employees at the center of the incident.

The incident at the core of the complaint occurred August 27, 2025. CNA-C, a certified nursing assistant, reported the incident to RN-F, a registered nurse, at approximately 4:00 PM that day. RN-F immediately reported it to DON-B, the director of nursing. So far, the chain moved quickly. What didn't move quickly was any report to the state.

The facility's own policy, which surveyors reviewed on-site, states that for alleged violations of abuse, the facility must report the allegation to the state agency immediately, but no later than two hours after the allegation is made or known. That language is not ambiguous. The Regional Nurse Consultant, identified in the report as RNC-G, initially told the surveyor that the facility's policy allowed up to 24 hours to report. The surveyor pulled out the actual policy and read it with RNC-G in the room. RNC-G acknowledged the discrepancy.

That moment, a senior clinical consultant misreading her own facility's written policy on abuse reporting timelines, sits near the center of what inspectors documented.

The reporting delay was not the only problem. When surveyors asked to see evidence that staff had been educated following the August 27 incident, the facility produced a collection of documents that raised more questions than they answered.

The nursing home had actually conducted an earlier round of education, on August 18, following a separate incident that predated August 27. The Social Services Director told surveyors that education had been completed approximately a week before August 27 because of that earlier situation. When the August 27 incident occurred, facility leadership decided not to conduct additional education immediately, on the reasoning that staff had just been trained. NHA-A, the administrator, later told surveyors the facility educated specific staff who worked on August 27 and provided reeducation through a nursing meeting.

The nursing meeting happened on September 3 and September 5, 2025. Surveyors reviewed the agenda notes from both sessions. Topics covered included the importance of maintaining professionalism, tone, respect, accountability, customer service expectations, and abuse reporting and resident rights. The agenda looked thorough enough on paper. Then surveyors checked the signature sheets.

CNA-C and RN-E had not signed the nursing meeting attendance records. When RNC-G showed surveyors alternative documentation, she produced signatures from CNA-C and RN-E on the August 18 education. When the surveyor asked when exactly CNA-C and RN-E had reviewed and signed that document, RNC-G said she did not know.

The individual training records were worse. RNC-G provided three separate copies of the facility's LTC Resident Abuse Prevention and Reporting Policy, each one purportedly used for a different employee's education. She also provided a copy of the LTC Behavioral Disturbance Policy used with CNA-C. Surveyors reviewed all four documents.

Every single one had the same problem. None of them contained a signed confirmation that the employee receiving the education had read it, understood it, or agreed to it.

The record for CNA-C's abuse prevention training stated on the last page that education was completed by DON-B via phone on August 27 and by RN-F in person that same day. DON-B and RN-F both signed the document. CNA-C did not. The behavioral disturbance policy record for CNA-C carried the same structure: administrator and nurse signed, CNA-C's confirmation absent.

The record for CNA-H showed RN-F's signature indicating the training was completed on August 27 as part of corrective action. CNA-H's own acknowledgment was not there. The record for RN-E showed DON-B's signature. RN-E's was not.

In each case, the facility had documentation that someone administered training. There was no documentation that anyone received it.

RN-F, speaking to surveyors during a September 10 phone conference that also included NHA-A and DON-B, said that after CNA-C reported the incident, RN-F immediately educated CNA-C about reporting requirements and told CNA-C directly that the incident should have been reported to administration right away, not hours later. That conversation happened the same afternoon as the incident. It was the right response. But the paperwork meant to memorialize it left out the most important signature.

The underlying conduct that triggered all of this was described in the report only briefly but without softening. CNA-C reported concerns about call light response times and staff telling residents to urinate in their briefs. After August 27, CNA-C continued reporting the same concerns. Staff were still not answering call lights. Residents were still being told to handle their own needs in their briefs.

RNC-G, when surveyors raised this, acknowledged the concern. She framed it as a staff retention issue related to abuse prevention and reporting. Whether she meant the facility was struggling to keep staff who followed the rules, or struggling to keep enough staff at all, the report does not clarify. What it does record is that the problem CNA-C originally flagged had not stopped by the time inspectors arrived two weeks later.

The deficiency was cited under F0610, which covers the obligation to report and investigate allegations of abuse. The level of harm was listed as minimal harm or potential for actual harm, and the number of residents affected was listed as few. Those are the lower rungs of the federal harm scale.

But the inspection narrative describes something the harm rating does not fully capture. A nursing aide saw what she believed was mistreatment of residents. She reported it. The facility responded with education sessions, policy reviews, phone calls, and a nursing meeting. It produced a stack of documentation. And when a surveyor sat down with that stack and checked whether the workers being trained had confirmed they understood any of it, the answer, across four separate records, was the same each time.

There was no signature.

CNA-C, the aide who raised the alarm in the first place, kept raising it after August 27. By the time inspectors arrived, she was still telling the facility that residents were being told to relieve themselves in their briefs rather than have someone answer the call light. Whatever training had been delivered in the two weeks between the incident and the inspection, the conduct she reported had not stopped.

The facility's nursing meeting agenda from early September listed accountability as a topic. The word appeared between tone and respect, in a list of challenges the staff were supposed to address together. It was on the agenda. What happened in the rooms where residents were waiting for someone to answer their lights was not on any document surveyors were shown.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Juliette Manor from 2025-09-10 including all violations, facility responses, and corrective action plans.

Additional Resources

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