Florence Health Services: Resident Attack Went Unreported - WI
The incident unfolded over four days in September at Florence Health Services, a long-term care facility at 5778 Chapin Street. On September 11, 2025, two residents sharing a room, identified in inspection records as R3 and R4, argued and slammed into each other. R4 told staff that R3 had started it. The facility's response was swift in one respect: it moved R3 out of the shared room within a day. R3 was relocated to a room that shared a bathroom with another resident, identified as R2.
Nobody investigated what had happened between R3 and R4. Nobody reported it to the state. Nobody updated R3's care plan to flag the verbal and physical aggression. Nobody told the care team that R3 had just fought with a roommate.
On September 13, two days after R3 was moved next door to R2, R3 walked into R2's room and slapped R2 in the face. Multiple times.
R2 was not a confused or incapacitated patient. According to R2's most recent assessment, completed in July 2025, R2 scored 15 out of 15 on the Brief Interview for Mental Status — a perfect score, indicating fully intact cognition. R2 was living with chronic obstructive pulmonary disease, alcoholic cirrhosis with fluid accumulation in the abdomen, type 2 diabetes, and respiratory failure with low blood oxygen. R2 understood exactly what was happening.
The facility investigated the September 13 attack on R2 and reported it to the state agency. The September 11 fight between R3 and R4 — the one that preceded it, the one that might have changed what happened — was never investigated and never reported.
Federal inspectors arrived on October 7 and 8, 2025, and began pulling records. The surveyor reviewed the facility-reported incident from September 13 and then pulled R2's medical record. Then came the interviews.
On October 8, at 2:39 in the afternoon, the surveyor sat down with Unit Manager H, who had been overseeing risk management at Florence Health Services since August 2025, just weeks before the September incidents. The unit manager had not known about the physical aggression between R3 and R4 on September 11. When the surveyor laid out the sequence of events, the unit manager acknowledged that the fight should have been investigated and reported. Then the unit manager went further: if interventions had been put in place and R3's care plan had been updated after the September 11 altercation, the September 13 attack on R2 might not have occurred.
That is not a conclusion the surveyor drew. That is what the unit manager said.
At 4:05 that afternoon, the surveyor interviewed the Director of Nursing, identified as DON-B, who also had not known the full extent of what had happened between R3 and R4 on September 11. The director verified that no investigation had been completed. R3's care plan should have been updated immediately to address the verbal and physical aggression, the director said. The care team should have been notified. Follow-up should have been completed on R4's care plan as well, to make sure R4 had appropriate support after being involved in the altercation.
The Director of Nursing stopped short of saying, with certainty, that a thorough investigation of the September 11 fight would have prevented the September 13 attack on R2. But the director did not dispute the sequence. The aggression should have been addressed. The care plan should have been updated right away. The team should have been told.
The inspection report classified the deficiency under F0600, the federal tag covering abuse and the obligation to protect residents from it. The level of harm was listed as minimal harm or potential for actual harm. Few residents were identified as affected.
What the classification does not fully capture is the geometry of the failure. R3 fought with R4 on September 11. The facility moved R3 out of that room, which looks, on its surface, like a response. But moving R3 without investigating, without updating a care plan, without alerting staff, without reporting to the state, meant the facility had simply relocated the problem. It placed R3 in a room sharing a bathroom with R2 and told nobody why.
R2, a person with a perfect cognition score who was already managing a serious cluster of medical conditions, was then left in proximity to a resident whose aggressive behavior had been witnessed, documented only in a relocation record, and otherwise buried.
The census records confirmed the timeline precisely. R3 moved into the shared room with R4 on September 10. R3 moved out on September 12. The fight happened on September 11. The attack on R2 happened on September 13.
Four days. Three residents. One investigation, conducted after the second incident. None conducted after the first.
The unit manager who acknowledged the failure had been in the risk management role for roughly a month when R3 and R4 fought. The director of nursing verified the investigation was never done. Neither suggested there was any ambiguity about what the facility's own policy required. The unit manager said it plainly: verbal and physical aggression between R3 and R4 should have been investigated and reported.
It was not.
Florence Health Services has not publicly responded to the inspection findings. For information on the facility's plan of correction, the Centers for Medicare and Medicaid Services directs inquiries to the nursing home or the state survey agency.
R2, who scored a perfect 15 on a cognitive assessment three months before being slapped in the face in their own room, was described in inspection records only by diagnoses and a test score. The inspection report does not say what R2 said about what happened, or whether anyone asked.
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.
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
Florence Health Services in Florence, WI was cited for violations during a health inspection on October 8, 2025.
The incident unfolded over four days in September at Florence Health Services, a long-term care facility at 5778 Chapin Street.
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.