Lakeland Health Care Ctr
LAKELAND HEALTH CARE CTR in ELKHORN, WI — inspection on September 2, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
physical and verbal abuse.
The Summary of factual investigative findings documented: .
After
jeopardy to resident health or substantiated.R1's challenging behaviors care plan initiated on 8/15/25 documents: [R1] has safety potential to be physically aggressive [related/to] dementia and poor impulse control as result of impaired cognition. [R1] may hit or strike out at staff or peers during cares.
Pertinent interventions
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 behaviors, facility staff entered a behavior care plan guiding staff in how to care for R1 when R1 has challenging behaviors.On 8/27/25 at 10:01 AM, Surveyor informed NHA-A and DON-B of the concern that R1 had dementia and had documented behaviors in May of 2025. A behavior care plan was not initiated to guide staff in caring for R1 and R1's MD was not notified of the behaviors. NHA-A stated that R1's behaviors were more sundowning and 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 R1 had continuing behaviors, facility staff sent a communication note to R1's doctor on 8/9/25 regarding R1's behaviors possibly being a symptom of UTI.
The facility did not follow up on 8/9 or 8/10/25 when the MD had not acknowledged the facility staff concerns about R1's behaviors. R1's behavior's continued, which led to a facility staff member, RN-D, yelling at R1 and holding R1's shoulders down which made R1 afraid.The facility's failure to protect a vulnerable resident from physical and verbal abuse created a reasonable likelihood for serious harm, including psychosocial harm, thus leading to a 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.
525625 09/02/2025
Lakeland Health Care Ctr 1922 Cty Rd Nn Elkhorn, WI 53121
R1's MD was not notified.
When R1's challenging behaviors continued into August, facility staff sent a
UTI.
The facility did not follow up on 8/9 or 8/10/25 when the physician had not acknowledged the
member, RN-D, yelling at R1 and holding R1's shoulders down which made R1 afraid. No additional information was provided.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.