Odd Fellow Home: Abuse Reporting Failures - WI

The resident, identified in inspection records only as R8, has congestive heart failure, respiratory failure, bipolar disorder, osteoarthritis, and a documented history of falls. A cognitive assessment completed November 4 gave R8 a perfect score, 15 out of 15, indicating fully intact cognition. R8 knew what had happened. R8 wrote it down.

The grievance R8 filed on October 24 described a CNA on the PM or night shift who "man-handled" them and "flopped my legs," leaving them tender. R8 told the CNA in the moment that they did not feel safe. The CNA, R8 wrote, was "rude, just not kind."

Then R8's condition changed. R8 was hospitalized, stayed longer than expected, and by the time R8 returned to the facility, R8 said they no longer recalled the incident. R8 told investigators they felt safe.

The facility treated that as a resolution.

The investigation was marked complete on November 7. The Assistant Director of Nursing signed off on a round of staff education that day, the lesson being that staff should take their time with residents and follow up when needed. The nursing home administrator signed the grievance form on November 17, the day before the inspection.

Nobody had interviewed other residents who might have been cared for by the same CNA. Nobody had collected witness statements from the staff who were working that shift. The facility's own policy required all of that: investigate immediately, identify the root cause, interview other potentially affected residents, obtain witness statements from involved staff.

When the inspector sat down with the nursing home administrator on the afternoon of November 18, the administrator confirmed the facility had no staff education signatures and no further investigative documentation for R8's allegation. The unnamed CNA was never identified in the inspection record. Whether that person was still working at the facility, still caring for residents, is not addressed in the report.

A separate violation documented during the same inspection involved a different resident and a different kind of institutional failure, one that also traced back to a gap between what a care plan said and what staff actually did.

That resident, identified as R1, fell at the facility. R1's care plan specified that transfers should be done using a sit-to-stand lift. Instead, a licensed practical nurse educated a certified nursing assistant to transfer R1 using a pivot transfer with a front-wheeled walker and two-person assist. The education was wrong. It did not reflect what R1's care plan required.

R1 fell during a transfer.

The nursing home administrator, when interviewed by the inspector on November 18, confirmed that R1's care plan at the time of the fall did call for a sit-to-stand lift, and confirmed that the education the LPN gave the CNA did not accurately reflect the correct technique for R1. Then the administrator said something that stopped the inspector short: the administrator said they did not feel the failure to follow the care plan was the primary cause of R1's fall.

The inspection report does not record what the administrator believed the primary cause was.

What the record does show is this: a resident had a documented transfer method in their care plan. A nurse taught a different method to the aide who would be doing the transfer. The resident fell. And the person responsible for the facility's operations told the inspector that the deviation from the care plan was not, in their view, the main thing that went wrong.

Taken together, the two violations describe something more corrosive than a single lapse. They describe a facility where the response to a reported fall was to minimize the role of the protocol that was ignored, and where the response to a reported abuse allegation was to close the file when the victim came back from the hospital and said they couldn't remember.

R8's grievance used plain language. "Man-handled." "Flopped my legs." "They are still tender." "I did not feel safe." These are not ambiguous words. They describe physical roughness during personal care, at night, when R8 was vulnerable and the CNA was the only one in the room.

The facility's policy existed precisely for situations like this one. Investigate immediately. Find the root cause. Talk to other residents the same staff member may have cared for. Get statements from witnesses while memories are fresh. None of that happened. Instead, a general reminder went out to staff about being patient and following up, and the matter was considered closed.

R8 came back from the hospital without the memory of what had been done to them. The facility accepted that as an ending.

The inspection was a complaint survey, meaning someone, a resident, a family member, or a staff member, had contacted regulators before the November 18 visit. The report does not identify who filed the complaint or what it alleged. What inspectors found when they arrived was a grievance that had been sitting in a file for three and a half weeks, signed off on by the administrator the day before they showed up, with no witness statements behind it and no staff signatures confirming anyone had been trained on anything.

The CNA R8 described as rude, as someone who did not slow down when a resident said they felt unsafe, remains unnamed in the public record.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Odd Fellow Home from 2025-11-18 including all violations, facility responses, and corrective action plans.

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