Florence Health Services: Abuse Investigation Failure - WI
The altercation happened September 11, 2025. The surveyor asked about it on October 8, 2025. Twenty-seven days had passed. Nobody had opened a file.
The Director of Nursing, identified in inspection records as DON-B, told the surveyor she wasn't aware of the extent of what had happened between the two residents. She said the facility takes incidents of abuse seriously. She verified the altercation should have been thoroughly investigated. The investigation still did not exist.
The two residents at the center of the incident shared a room at the Florence, Wisconsin facility. Both had moderate cognitive impairment. Both were navigating the confined space of a shared room with the limited tools available to them, one a wheelchair, one a walker.
The first resident, identified in inspection records as R3, had been living at the facility with dementia with behavioral disturbance and psychotic disturbance, along with anxiety and a history of repeated falls. A cognitive assessment conducted less than three weeks before the altercation gave R3 a score of 10 out of 15, placing R3 in the range of moderate cognitive impairment. R3 had an activated Power of Attorney for healthcare decisions, meaning someone outside the facility had legal authority to make medical choices on R3's behalf.
The second resident, R4, had diagnoses including cerebral infarction, cognitive communication deficit, and depression. A cognitive assessment conducted two weeks after the altercation gave R4 a score of 9 out of 15, also indicating moderate cognitive impairment.
Two residents with dementia and cognitive damage, sharing a room. This is not an unusual arrangement in American nursing homes. It is also not an arrangement without risk.
According to a progress note written the night of September 11, 2025 at 9:24 PM, R3 was in bed and attempted to take R4's soda. R4 was R3's roommate. What followed, according to that note, involved yelling, swearing, threatening, and the two residents pushing a wheelchair and walker against each other.
The note was written. R3 was moved out of the room after the incident. And then, as far as the facility's formal processes were concerned, nothing else happened.
When the surveyor interviewed R4 on October 8, R4 remembered the argument. R4 said the two residents had slammed into each other. R4 identified R3 as the initial aggressor. R4 confirmed R3 had been moved out of the room following the incident.
R3's memory of the event was different. When the surveyor interviewed R3 that same afternoon, R3 did not recall any altercation with R4. R3 also told the surveyor that nobody would live through it if they were aggressive with R3.
That statement, delivered to a federal surveyor during a complaint inspection, came from a resident with documented dementia with behavioral disturbance and moderate cognitive impairment. It came nearly a month after an incident that the facility's own nursing director acknowledged should have triggered a formal investigation. The investigation that should have examined what R3 remembered, what R3 was capable of, and what risks R3 posed to others in the building had never been opened.
The facility's own abuse, neglect, and exploitation policy, last revised July 15, 2022, states that an immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation occurs. The policy assigns a designated leadership position responsibility for reporting to the State Survey Agency and other officials. The policy requires ongoing oversight and supervision of staff to ensure its policies are carried out as written.
None of that happened here.
What happened instead was a progress note. A room change. And silence.
The question of what Florence Health Services owed these two residents after September 11 is not complicated by the facts of the case. R4 described being slammed into. R3 had documented behavioral disturbance as a diagnosis. The two had been placed together as roommates. When the arrangement produced a physical confrontation involving mobility equipment being used as weapons, the facility's obligation under its own written policy was immediate investigation.
The word "immediate" appears in that policy. The investigation that was supposed to be immediate was still missing when a surveyor arrived twenty-seven days later as part of a complaint inspection.
An investigation, had one been conducted, would have served multiple purposes. It would have documented what staff witnessed, what residents reported, and what the medical records showed about injuries or behavioral changes in the days following. It would have created a record that could inform decisions about whether R3 and R4 could safely be housed in proximity to each other. It would have determined whether the incident met the definition of abuse under Wisconsin law, which would have triggered mandatory reporting to state officials.
None of that documentation exists. The surveyor's request for the file produced nothing, because there was no file.
DON-B's acknowledgment that she wasn't aware of the extent of the altercation raises its own questions. The progress note from September 11 described a specific sequence of events in detail: the attempt to take the soda, the verbal escalation, the physical confrontation with the wheelchair and walker. That note was in R3's medical record, which the surveyor reviewed on October 7. The Director of Nursing, the person her facility's own policy designates as responsible for oversight of abuse-related incidents, had not seen it, or had seen it and not recognized what it required.
She told the surveyor the facility takes incidents of abuse seriously. The record of what followed September 11 does not support that statement.
R4, who told the surveyor about being slammed into, who identified R3 as the aggressor, who confirmed the room change after the incident, did so without the benefit of a formal investigation having been conducted on their behalf. R4's account, given to a surveyor nearly a month after the fact, is the closest thing to a documented interview that exists in this case. The facility did not conduct one. The surveyor did.
R3, who cannot recall the incident, who has dementia with behavioral disturbance, who told a surveyor that nobody would survive aggression directed at R3, remained a resident of the facility as of the inspection date. The question of what the facility understood about R3's behavioral risks, and what plan existed to manage those risks in a shared living environment, was not answered by any investigation. Because there was no investigation.
The inspection was conducted October 8, 2025. The deficiency was cited at a level of minimal harm or potential for actual harm. The surveyor classified it as affecting few residents.
R4 described being slammed into by a roommate wielding mobility equipment. That is what few residents and minimal harm looks like in the language of federal nursing home oversight.
What it looks like from the inside of a shared room at Florence Health Services, on the night of September 11, 2025, when a soda became the catalyst for a physical confrontation between two people with moderate cognitive impairment and no ability to protect themselves through the formal processes that were supposed to exist for exactly this situation, is something the facility chose not to document.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Florence Health Services from 2025-10-08 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
Florence Health Services in Florence, WI was cited for abuse-related violations during a health inspection on October 8, 2025.
The altercation happened September 11, 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.