Burnett Medical Center: Insulin Safety Failures - WI
The October 2025 inspection, triggered by a complaint, found that licensed practical nurse LPN E had been managing blood sugar crises for a resident identified as R1 without physician notification. When R1's blood glucose meter read "high," staff would document the reading, wait ten minutes, retake the blood sugar, and administer insulin once the number dropped to 350. Nobody called the doctor.
LPN E told the inspector that a blood sugar over 400 would prompt a physician call. But there was nothing in R1's medication administration record specifying when to make that call. In practice, the calls weren't happening.
It went further than documentation gaps. LPN E stated plainly that R1 would request the amount of insulin R1 wanted, and staff would administer that amount. The physician's orders, whatever they said, were not what determined the dose. The resident's preference was.
LPN E also said she had never received training at the facility on when blood sugars are out of range and when to notify the physician.
The facility's interim chief executive officer, identified as CEO D, acknowledged the problem directly when interviewed the following morning. CEO D said there was "no question" nurses were expected to follow provider orders and communicate with the provider when a resident refuses medications or when blood sugars change, "especially with a brittle diabetic like R1." CEO D said the facility "can definitely do better in this area."
Brittle diabetes refers to a form of the disease marked by severe, unpredictable swings in blood glucose that are difficult to control and carry serious risks, including seizure, loss of consciousness, and death.
R1's blood sugars were swinging. The physician didn't know.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Burnett Medical Center from 2025-10-29 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 23, 2026 · Our methodology
BURNETT MEDICAL CENTER in GRANTSBURG, WI was cited for violations during a health inspection on October 29, 2025.
LPN E told the inspector that a blood sugar over 400 would prompt a physician call.
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.