The morning incident at Greentree Health and Rehabilitation Center occurred at approximately 6:30 AM on July 24, 2025. Staff separated the residents but failed to file the required abuse report for nearly ten hours, federal inspectors found.
Licensed Practical Nurse 1 told investigators that another staff member informed her they had witnessed the attack. The nurse said she then observed the victim, who "appeared upset and did not want the interaction to occur."
The aggressor had wrapped arms around the victim's neck, pulled them close, then pinched their ear when the victim became distressed about the unwanted contact.
"LPN1 agreed LPN1 should have reported the first occurrence which may have prevented the second occurrence," inspectors wrote.
The facility's own policy, dated July 2024, requires all alleged abuse violations to be reported within two hours to the state licensing agency. The policy states that residents must be free from abuse by anyone, including other residents.
Instead, staff waited until approximately 3:55 PM that same day to file a report. They only acted after the same resident attacked the victim again.
The aggressor suffers from schizophrenia, major depressive disorder, and cognitive communication deficits, according to medical records. The victim has Alzheimer's disease and dementia.
Federal inspectors discovered the unreported morning incident while investigating the afternoon attack. A facility misconduct report dated July 30 acknowledged that staff had witnessed the earlier abuse but failed to document it.
The Director of Nursing confirmed to investigators that "staff should have reported the incident that occurred on the morning of 7/24/25."
This reporting failure violated federal regulations requiring nursing homes to immediately report suspected abuse and notify proper authorities of investigation results. The facility received a citation for minimal harm with potential for actual harm affecting few residents.
The inspection occurred in response to a complaint filed with federal regulators. Greentree Health and Rehabilitation Center is located at 70 Greentree Road in Clintonville, Wisconsin.
Federal law mandates that nursing home residents have the right to be free from abuse, neglect, and exploitation. This protection extends to incidents involving other residents, staff, consultants, volunteers, family members, and visitors.
The facility's abuse prevention policy explicitly states that residents "must not be subjected to abuse by anyone" and that violations require immediate reporting. The policy covers physical abuse, involuntary seclusion, and improper restraint use.
Licensed Practical Nurse 1 acknowledged during the October 9 interview that the first incident should have been reported immediately. The nurse admitted that proper reporting might have prevented the second attack from occurring.
Both residents involved in the incidents have significant cognitive impairments that affect their ability to understand and respond to social situations. The aggressor's mental health conditions include disorders that can impact impulse control and social interactions.
The victim's Alzheimer's disease and dementia make them particularly vulnerable to abuse and unable to effectively protect themselves or report incidents independently.
Staff separation of the residents after the morning incident demonstrated they recognized the interaction as problematic and potentially harmful. However, this intervention alone did not satisfy federal reporting requirements.
The facility's failure to report abuse within the required two-hour timeframe left state authorities unaware of the incident for most of the day. This delay prevented immediate investigation and protective measures.
Federal inspectors found that the nursing home's internal misconduct report, completed six days after the incidents, revealed the systematic failure to properly document and report the morning abuse.
The Director of Nursing's acknowledgment that staff should have reported the first incident confirmed the facility's recognition of the policy violation.
Greentree Health's abuse prevention policy requires reporting suspected violations "via phone or in writing within two hours to the State Licensing Agency." This standard exists to ensure rapid response to protect vulnerable residents.
The inspection report indicates this was not an isolated oversight but a fundamental failure of the facility's abuse reporting system. Staff witnessed clear signs of unwanted physical contact and emotional distress but chose not to follow established procedures.
The victim's tearful reaction and obvious distress should have triggered immediate protective action and reporting, according to federal standards for nursing home care.
Both incidents involved the same aggressor and victim, suggesting a pattern of behavior that required immediate intervention and ongoing monitoring to prevent future harm.
The facility's acknowledgment that proper reporting of the first incident might have prevented the second demonstrates the real-world consequences of failing to follow abuse reporting protocols.
Federal regulations exist specifically to protect residents like these two individuals, whose cognitive impairments make them unable to advocate for themselves or escape harmful situations without staff intervention.
The Licensed Practical Nurse's admission of responsibility represents a rare acknowledgment of how reporting failures can directly lead to additional abuse of vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greentree Health and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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