Burnett Medical Center
BURNETT MEDICAL CENTER in GRANTSBURG, WI — inspection on April 29, 2026.
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
authorities.
record review and interview, the facility did not implement policies and procedures for ensuring the
physical abuse was not reported immediately, but no later than 2 hours to the State Agency and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1).On 03/22/26, the facility was made aware of R1's allegation of abuse.
The facility did not report this allegation to the State Agency (SA) or to local law enforcement within 2 hours.
This is evidenced by:Facility policy titled, Abuse, neglect, Mistreatment and Misappropriation of Resident Property, with revised date of 07/10/25, states: G.
Reporting and Response Components.The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.to the administrator of the facility and the DQA in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility.R1 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, type 2 diabetes mellitus, emphysema, bipolar disorder, depression, and generalized anxiety.
Minimum Data Set, dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 3/15, indicating severe cognitive impairment, behaviors of inattention fluctuate, and a PHQ-9 score of 5, meaning mild depression.R1's progress note dated 03/22/26 documented .At 0115, writer responded and observed resident attempting to stand unassisted next to bed.
Writer and CNA guided resident to a safe seated position.
Resident made repeated accusations toward staff, stating, You're beating me. and used profane language.
Staff provided reassurance that care was for resident's safety and attempted to de-escalate by reducing stimulation and giving resident space.
Resident continued yelling, kicking, and making accusations toward staff .Writer notified DON (Director of Nursing) at 0250 to report incident and resident's statements/behavior. DON acknowledged report and stated she would follow-up with resident on Monday.On 04/29/26 at 12:31 PM, Surveyor interviewed Registered Nurse (RN) C about R1's abuse allegation. RN C stated R1 was agitated and tried to ensure R1 was safe when R1 was trying to self-transfer. R1 started making allegations of staff beating R1. RN C stated she immediately reported the incident to DON B and wrote out statements and had staff write statements. RN C stated RN C and the Certified Nursing Assistants (CNA)s continued to work the remainder of their shift.On 04/29/26 at 2:33 PM, Surveyor interviewed DON B regarding R1's allegation of abuse by staff. DON B stated DON B got notified around 2:30 AM that day and staff stated R1 was agitated and was calm now. DON B told staff DON B will look at this on Monday [3/23/26]. DON B stated DON B did not report the allegation to the State Agency (SA), police, or remove staff from working with residents until the investigation was complete. DON B stated on Monday 3/23/26, R1 recanted R1's statement.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
525558 04/29/2026
Burnett Medical Center 257 W St George Ave Grantsburg, WI 54840
12:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN) F about resident abuse.
Surveyor
abuse occurring in the facility and would report to charge nurse and DON immediately. LPN F stated
is no evidence documented in R1's medical record of a skin assessment on R1 after R1 alleged abuse occurred by staff.
There is no documentation regarding an investigation of the allegation in R1's record.On 04/29/26 at 2:33 PM, Surveyor interviewed DON B about investigating R1's allegation of abuse by staff. DON B stated DON B interviewed R1 on Monday [3/23/26] and R1 recanted R1's statement. R1 stated staff did not hurt R1 and R1 wanted to be left alone. DON B stated no other interviews were conducted with other residents or staff only the written statements from the staff involved.
After speaking with R1 it was determined the allegation did not occur.
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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.