Clark County Rehab: Guardian Never Told of Abuse - WI
On October 14, 2025, a federal surveyor sat down with Guardian H and asked whether she knew about something that had happened to her ward on August 5th and 6th. Guardian H said no. No one at Clark County Rehabilitation & Living Center had told her anything. Not about the incident. Not about the investigation. Not about the finding, two weeks after the incident, that the allegation was substantiated.
It was, she told the surveyor, the first time she was hearing of any of it.
The resident at the center of this — identified in inspection records only as R1 — had been placed under court-appointed permanent guardianship in April 2025 because of incompetency. A court had also issued an Involuntary Order to Treat with Psychotropic Medications the following day, on May 1st. R1 could not make her own medical decisions. That was the entire legal point of the guardianship arrangement. And yet when staff at the facility were alleged to have held R1's arms and face while forcing medication, the person legally responsible for R1's welfare was cut out entirely.
R1 had been admitted to Clark County Rehabilitation with anxiety disorder, depression, a personality disorder, and an unspecified psychosis not attributable to substances or a known physiological condition. The most recent cognitive assessment on record gave R1 a BIMS score of zero, the lowest possible score, indicating severely impaired cognition. R1 experienced delusions. R1 rejected care four to six days out of every week. The care plan flagged that pushing R1 on medication refusals, even verbally, triggered verbal aggression and physical threats, and directed staff not to repeat attempts after a first refusal but to step away and re-approach.
What happened on August 5th and 6th, according to the anonymous complaint that triggered the inspection, was the opposite of that. Staff allegedly held R1's arms and face while administering medications.
The facility's own investigation confirmed it happened.
Director of Nursing B was notified of the allegation on August 12th, a week after the incidents. The facility interviewed staff and residents, retrained direct care workers, and notified the provider. On August 19th, seven days after the investigation began, the facility formally determined the allegation was substantiated. Abuse had occurred. The documentation of that conclusion sat in the facility's records.
Nobody called the guardian.
The facility's own written policy, a document titled "Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure," says the administrator or designee will inform the resident or resident's representative when a report of an incident is made and that an investigation is underway. It also says the administrator or designee will inform the resident or responsible party of the results of the investigation.
The facility had a policy. The facility had a confirmed finding. The facility had a legal guardian on record whose contact information was in R1's file. The guardian received nothing.
When the surveyor interviewed Director of Nursing B on October 14th at 1:03 in the afternoon, DON B said she was pretty sure the guardian had been notified and offered to check for documentation. No additional documentation was ever provided to the surveyor.
Pretty sure.
The inspection that uncovered this failure was triggered by an anonymous complaint and conducted between October 13th and 15th, 2025. By the time inspectors arrived, more than two months had passed since the abuse finding. Guardian H had been making decisions about R1's care, signing off on treatment, fielding updates from the facility on other matters, during all of that time, without knowing that staff had physically restrained her ward's arms and face to force medication into her.
The gap here is not a paperwork technicality. R1's guardianship existed precisely because R1 could not protect herself, could not evaluate what was happening to her, could not report it, could not demand accountability. A BIMS score of zero means the cognitive tools that most people use to navigate a harmful situation, memory, judgment, communication, were not available to R1. The guardian was the mechanism the legal system put in place to fill that gap. The facility's failure to notify her did not just violate a policy. It left the person legally responsible for R1's safety operating without information she needed to do that job.
The care plan for R1, initiated in January 2025, had already identified the central tension in her care: she sometimes refused medication, and pushing her led to escalation. The plan's instruction was explicit. One attempt. If refused, do not press. Re-approach later. Notify the physician and the guardian of any change in condition. The guardian notification was written into the protocol, not as a bureaucratic add-on, but as a required step when R1's care deviated from the expected.
What happened in August was a deviation. Staff did not step away. Staff held her.
The court order authorizing involuntary psychotropic medication treatment, issued in May, gave the facility legal authority to administer medications R1 might refuse. It did not authorize staff to physically restrain her during that process without accountability, and it did not suspend the obligation to keep her guardian informed.
Clark County Rehabilitation's inspection record for this visit lists the deficiency at a level of minimal harm or potential for actual harm. That classification reflects the regulatory framework inspectors apply, not a judgment about what Guardian H lost by being kept in the dark for two months, or what R1 lost by having her legal advocate sidelined during the period immediately following a confirmed abuse finding.
The surveyor's notes do not record what Guardian H said after confirming she had never been told. The report captures only the fact of her ignorance and its duration. Two months. A substantiated finding. No call.
DON B's response, that she was pretty sure the notification had happened, followed by silence when asked to produce evidence of it, is the last thing the inspection record shows from the facility's side of the conversation.
Guardian H is still R1's legal guardian. R1 is still a resident at Clark County Rehabilitation & Living Center.
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.
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 9, 2026 · Our methodology
CLARK COUNTY REHABILITATION & LIVING CENTER in OWEN, WI was cited for abuse-related violations during a health inspection on October 15, 2025.
No one at Clark County Rehabilitation & Living Center had told her anything.
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.