Clark County Rehab: CNA Gave Psych Meds Illegally - WI
That finding sits at the center of a complaint inspection completed October 15, 2025, at Clark County Rehabilitation & Living Center, a nursing home on County Highway X in Owen, Wisconsin. Federal inspectors cited the facility for allowing unlicensed staff to administer prescription medications, a practice the facility's own written policies explicitly prohibit.
The resident at the center of the complaint, identified only as Resident 1 in inspection records, was admitted with anxiety disorder, depression, a personality disorder affecting cognitive function, and an unspecified psychosis not attributed to any known physiological condition. Their physician had ordered two psychiatric medications: haloperidol lactate, an antipsychotic given once daily for behavior, agitation, and mood, and diazepam, the generic form of Valium, prescribed every eight hours as needed for anxiety.
Haloperidol is among the more potent antipsychotic drugs used in long-term care. Diazepam is a controlled benzodiazepine. Both carry significant risks if administered incorrectly, including sedation, respiratory depression, and, in elderly or cognitively impaired patients, an elevated risk of falls and injury. Neither is the kind of medication a facility hands off casually.
Clark County Rehabilitation handed them off anyway.
According to the facility's own investigation records, CNA F admitted to administering Resident 1's medications by mixing them into food and ice cream and by loading them into a syringe. When Resident 1 resisted, CNA F held the resident's chin while a second staff member held the resident's hand, and CNA F squirted the medication directly into the resident's mouth. A registered nurse, identified as RN E, was present and supervising while this happened.
The investigation began on August 12, 2025, when Director of Nursing B was made aware of an abuse allegation involving Resident 1. Interviews were conducted with CNA F, a second CNA identified as CNA G, and RN E, all named in the complaint. CNA F's admission about the medication administration method came out of those interviews.
When inspectors later pulled CNA F's personnel file, they found no record of any medication administration training. None.
That absence matters because the facility's own policies are explicit on the subject. A policy titled "Medication Administration & Treatment by Certified Nursing Assistants" states that nursing assistants may not administer any medications, with two narrow exceptions: applying prescription or nonprescription topical creams to unbroken skin during daily care, and providing oral care with mouthwashes. A separate medication administration policy states that all medications shall be administered by a licensed nurse or nurse technician per physician order.
Haloperidol by syringe into a resisting resident's mouth is not topical cream on unbroken skin. It is not mouthwash.
The Director of Nursing knew this was happening and considered it acceptable.
On October 14, 2025, the day before the inspection was completed, an inspector interviewed Director of Nursing B directly about what the facility's investigation had uncovered. DON B confirmed that it was common practice at the facility for CNAs to administer medications while a nurse directly supervised. When the inspector asked whether CNAs received any additional training or competency evaluation before being allowed to do this, DON B said no. No competency evaluation was needed, DON B explained, as long as the nurse prepared the medications and directly observed the CNA giving them.
"As long as the nurse delegated the medication administration task to the CNA," DON B told the inspector, "it was completely acceptable for unlicensed staff to administer medications as long as the RN directly supervised."
That position is not supported by the facility's own written policies, which make no exception for nurse supervision or delegation when it comes to oral medications. It is also not supported by Wisconsin's framework for nursing practice, which governs what tasks can and cannot be delegated to unlicensed staff, and which draws a clear line around medication administration.
What DON B described was not an isolated breakdown or a single employee going rogue. It was a system. CNAs were being used as the hands delivering controlled psychiatric medications to a resident who did not take them willingly, with a nurse standing nearby watching it happen. The nurse's presence was treated as the thing that made it legal. It did not make it legal.
The physical component of what happened to Resident 1 also deserves attention on its own terms. This was a resident with documented anxiety, depression, psychosis, and cognitive impairment. When that resident resisted taking medication, the response was to have one staff member hold their hand and another hold their chin and force the drug in. The facility's investigation flagged this as an abuse allegation. Inspectors cited the medication administration violation. The two things happened together, in the same room, to the same person.
CNA F did not act alone. CNA G was present and holding the resident's hand. RN E was supervising. The facility's director of nursing, when asked about it two months later, defended the practice as standard.
The inspection report covers one resident and one deficiency tag. The harm level is listed as minimal harm or potential for actual harm. That classification reflects the regulatory framework inspectors work within, not a verdict on what it felt like to be Resident 1, cognitively impaired and diagnosed with psychosis, having their chin held while someone pushed a syringe of antipsychotic medication into their mouth.
Clark County Rehabilitation's policies, both of them, exist on paper. The medication administration policy carries no date. The CNA medication policy carries no date. Neither appears to have been enforced in any consistent way, given that the director of nursing characterized what CNA F was doing as common practice across the facility, not an exception someone had quietly carved out.
What the inspection record does not contain is any indication that the facility's approach changed before inspectors arrived. DON B's October 14 interview does not read like someone who had already corrected a problem. It reads like someone explaining why there was no problem to correct.
Resident 1 came to Clark County Rehabilitation with a psychiatric history, a diagnosis of psychosis, and a prescription for one of the more powerful antipsychotic medications used in nursing home care. They ended up with a CNA holding their face and a syringe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark County Rehabilitation & Living Center from 2025-10-15 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 5, 2026 · Our methodology
CLARK COUNTY REHABILITATION & LIVING CENTER in OWEN, WI was cited for violations during a health inspection on October 15, 2025.
Haloperidol is among the more potent antipsychotic drugs used in long-term care.
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.