Lakeland Health Care Ctr
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
finding of immediate jeopardy. The immediate jeopardy was removed on 8/11/25 when staff were educated
on abuse and residents rights.The immediate jeopardy was corrected on 8/25/25 after the facility completed
the following:-All staff education on verbal and physical abuse which started on 8/11/25.-All staff education
on resident's rights including: Freedom from mistreatment, Freedom from physical restraints, Treatment options (including the right of the resident to refuse care or treatment), Self-determinations (including the right of the resident to make decisions relating to care), and the Right of the Resident to be treated with courtesy and respect which started on 8/11/25.-All staff meeting on 8/18/25 which included additional abuse training, as well as burnout and stress management of staff. Staff not in attendance had the training available online to view on 8/25/25.-Audit started on 8/11/25 included check-ins with 5 residents a day to cover any resident concerns. Audits will continue for 4 weeks.-Audit started on 8/11/25 included check-ins with 5 staff a day to cover abuse, and staff stressors. Audits will continue for 4 weeks.-Grievance audit started on 8/11/25 included facility staff reviewing resident grievances each weekday for 4 weeks. Staff to audit for any area of concern related to abuse or misconduct.-Staff interviewed other residents in the facility
on 8/11/25.-Police were notified on 8/11/25.Based on this determination, the citation F-F600 was cited as past non-compliance.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakeland Health Care Ctr
1922 Cty Rd Nn Elkhorn, WI 53121
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0744
F 0744 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
potential to be physically aggressive [related/to] dementia and poor impulse control as result of impaired cognition. [Resident R1] may hit or strike out at staff or peers during cares. Pertinent interventions initiated on 8/15/25 include: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Communication: provide physical and verbal cues to alleviate anxiety: give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmy away, and approach later.Surveyor noted, after over 3 months of challenging and aggressive behaviors, facility staff entered a behavior care plan guiding staff in how to care for Resident R1 when Resident R1 has challenging behaviors.On 8/27/25 at 10:01 AM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that Resident R1 had dementia and had documented behaviors in May of 2025. A behavior care plan was not initiated to guide staff in caring for Resident R1 and Resident R1's MD was not notified of the behaviors. NHA-A stated that Resident R1's behaviors were more sundowning and Resident R1 lives in the memory care unit. NHA-A stated that NHA-A understands the concern about the care plan but stated that staff on the unit know what to do because of their training.
Surveyor continued and shared concern that when Resident R1 had continuing behaviors in July and a behavior care plan was not initiated and Resident R1's MD was not notified. When Resident R1's challenging behaviors continued into August, facility staff sent a communication note to Resident R1's doctor on 8/9/25 regarding Resident R1's behaviors possibly being a symptom of UTI. The facility did not follow up on 8/9 or 8/10/25 when the physician had not acknowledged the facility staff concerns about Resident R1's behaviors. Resident R1's behavior's continued, which led to a facility staff member, RN-D, yelling at Resident R1 and holding Resident R1's shoulders down which made Resident R1 afraid. No additional information was provided.
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LAKELAND HEALTH CARE CTR in ELKHORN, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELKHORN, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAKELAND HEALTH CARE CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.