Juliette Manor: Staff Told Resident to Urinate in Brief - WI
The incident happened on August 27, 2025. A second nursing assistant, identified in inspection records as CNA-C, was present and witnessed the entire exchange. CNA-C watched CNA-D yell at the resident, identified only as R1, and refuse to help them. CNA-C told inspectors that CNA-D "always" tells R1 to urinate in their brief, suggesting this was not a single lapse but a pattern.
CNA-D left the room. Within seconds, a registered nurse entered.
CNA-C reported that R1 told the nurse directly, in the moment, that staff had just told them to piss in their brief. The nurse, identified as RN-E, was now aware of what had happened. CNA-D was still in the building, still on shift. The reporting window the facility's own policy describes had not yet closed.
RN-E did not report the incident.
CNA-D finished the shift and left for the day.
CNA-C went home. The incident stayed with them. Later that same day, CNA-C returned to the facility at approximately 1:00 PM for scheduled training. The weight of what they had seen apparently did not lift. At approximately 3:00 PM, CNA-C reported the incident to another nurse, RN-F. By the time the report was made, it was somewhere around four hours after the abuse had occurred.
RN-F told CNA-C they should have reported immediately. That instruction was accurate. What it could not do was undo the delay.
When inspectors interviewed the facility's Nursing Home Administrator, Director of Nursing, and RN-F together by phone on September 10, 2025, the Director of Nursing confirmed that CNA-C had reported to RN-F. RN-F confirmed the timeline: the report came in on August 27 at approximately 4:00 PM. RN-F said they immediately educated CNA-C about reporting requirements after receiving the information.
None of that education explains why RN-E, the nurse who heard the allegation from the resident's own mouth while standing in the room, did not report it.
The inspection report does not record any explanation from RN-E. It does not indicate whether RN-E was disciplined, counseled, or interviewed in any detail. The record of what RN-E knew and when they knew it sits in the narrative largely unresolved.
What the inspection does record is what happened when the surveyor spoke with the facility's Regional Nurse Consultant, identified as RNC-G, at 4:08 PM on September 10. RNC-G told the surveyor that the facility's policy allowed up to 24 hours to report if there was no serious bodily injury.
That was wrong.
The surveyor reviewed the facility's own written policy with RNC-G on the call. The policy did not say 24 hours for non-injury cases. It said that for alleged violations of abuse, regardless of whether serious bodily injury occurred, the facility must report the allegation to the state agency immediately, and no later than two hours after the allegation is made. RNC-G acknowledged the language in the policy. The regional consultant responsible for guiding the facility's compliance had been operating under a misreading of the rule.
The facility's own investigation, completed before the inspection, had already substantiated that abuse occurred. That finding came from inside the building. Juliette Manor confirmed, through its own process, that what CNA-D did to R1 on the morning of August 27 met the definition of abuse. That conclusion is not in dispute.
What the inspection documents is the gap between that conclusion and what the facility actually did with it in the hours it mattered most.
CNA-C, who reported the incident, told inspectors they knew they should have reported sooner. That acknowledgment is in the record. CNA-C did not ignore what they saw. They came back to the building on their own time, on a training day, and told someone. That took more initiative than either CNA-D or RN-E showed.
But CNA-C was not the charge nurse. CNA-C was not the person who stood in the room while R1 described, in plain language, what a staff member had just done to them. That person was RN-E, and the inspection record does not reflect that RN-E faced any consequence for failing to act on information received directly from the resident.
The two-hour reporting window exists for a reason. It is the interval during which staff who committed abuse are still on the premises and can be removed from resident contact. It is the window during which a fresh investigation can begin, witnesses can be separated, and the resident can be protected from further contact with the person who harmed them. CNA-D was still in the building, still working, for an unknown portion of that window. The record does not say how long CNA-D remained after the incident before finishing the shift and leaving.
By the time CNA-C reported to RN-F at 4:00 PM, the moment for any of that had passed.
Juliette Manor is located at 482 Oak Street in Berlin, Wisconsin, a small city of roughly 5,000 people in Green Lake County. The facility carries CMS certification number 525286. The complaint inspection that produced this finding was completed on September 10, 2025.
The inspection cites a single deficiency, tagged F0609, rated at the level of minimal harm or potential for actual harm, affecting a small number of residents. That rating reflects the regulatory framework's assessment of documented injury. It does not capture what it is like to be R1, dependent on staff for the most basic physical assistance, told by someone who is supposed to help you to urinate in your brief instead, and then to tell a nurse what just happened, in your own words, and have that nurse leave the room without doing anything about it.
R1's name does not appear in the inspection report. Their age, their diagnosis, the nature of the assistance they needed that morning are not recorded in the public document. What is recorded is that they told someone in authority what had been done to them, and that person did nothing, and that the facility's regional consultant did not understand the reporting rule until a federal surveyor read the facility's own policy back to them over the phone.
The facility confirmed the abuse happened. It took more than two hours to tell anyone who was required to know.
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
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 29, 2026 · Our methodology
Juliette Manor in Berlin, WI was cited for violations during a health inspection on September 10, 2025.
The incident happened on August 27, 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.