Clark County Rehabilitation & Living Center
CLARK COUNTY REHABILITATION & LIVING CENTER in OWEN, WI — inspection on October 15, 2025.
Found 7 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
(injury/decline/room, etc.) that affect the resident.
interview and record review, the facility did notify the resident representative of a change in condition
regarding R1. R1's legal guardian was not notified of incident or subsequent investigation findings.This is evidenced by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: G.
Reporting and Response: The Administrator or designee will inform the resident or resident's representative of the report of an incident and that in investigation is being conducted.
The Administrator or designee, will inform the resident and/or responsible party the results of the investigation.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's most recent significant change Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R1 was noted to have physical, verbal, and other behavioral symptoms occurring 1-3 days, delusions present, and rejection of cares occurred 4-6 days. R1 was independent with eating, sit to lying, sit to stand, and chair/bed transfers. R1 was receiving antipsychotic and antianxiety medications. No use of physical restraints.R1's care plan, with an initiated date of 01/28/25 and a target date of 08/04/25, states: Medication non-compliance r/t unspecified schizophrenia spectrum and other psychotic disorder and personality disorder with interventions of If R1 refuses to take medication attempt to determine the reason for refusal; if no response after 1 attempt do not use progressive verbal prompts as it leads to verbal aggression and physical threats, re-approach in a few minutes, notify physician and guardian of change of condition.Surveyor reviewed R1's medical record and noted:04/30/25 - documentation of court appointed permanent guardianship due to incompetency.05/01/25 - documentation of an Involuntary Order to Treat with Psychotropic Medications ordered by the court.Between 10/13/25 - 10/15/25, Surveyor investigated an anonymous complaint regarding an allegation of facility staff holding R1's arms and face while administering medications.
Surveyor reviewed facility's documentation and noted that on 08/12/25, Director of Nursing (DON) B was notified of an allegation of abuse that occurred on 08/05/25 and 08/06/25.
The facility completed an investigation and determined on 08/19/25 that the allegation was substantiated.
The facility completed staff and resident interviews, re-education with direct care staff, and notified the provider of the incident. No documentation of informing the guardian was noted.On 10/14/25 at 9:22 AM, Surveyor interviewed R1's Guardian (G) H.
Surveyor asked G H if she was aware of incident that occurred on 08/05/25 and 08/06/25. G H stated no one in the facility had informed her of this occurring and no details of an investigation or findings of abuse being confirmed were communicated. G H told Surveyor this was the first time hearing of this event.On 10/14/25 at 1:03 PM, Surveyor interviewed DON B regarding incident. DON B stated that she was pretty sure the guardian was notified but would double-check for documentation to provide the surveyor. No additional documentation was provided.
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
525403 10/15/2025
Clark County Rehabilitation & Living Center W4266 County Highway X Owen, WI 54460
dates of the two noted observations were determined to be 08/05/25 and 08/06/25 during the
525403 10/15/2025
Clark County Rehabilitation & Living Center W4266 County Highway X Owen, WI 54460
quality. DON B stated this incident was not reported.
Surveyor asked if the incident was reported to
disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological
sister reporting an allegation of abuse.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning R3.
The facility did not submit a Facility Reported Incident (FRI) concerning allegation of abuse to the State Agency. On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding incident. DON B stated that R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that R3 might call to report this.
Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.
525403 10/15/2025
Clark County Rehabilitation & Living Center W4266 County Highway X Owen, WI 54460
of Nursing (DON) B.On 08/12/25, DON B was notified and began an investigation. On 08/19/25,
enforcement was contacted to report allegation of abuse.On 10/14/25 at 1:10 PM, Surveyor
State because it was late being reported to DON and State survey agency would be giving them a cite for reporting late so decided not to report.
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Clark County Rehabilitation & Living Center W4266 County Highway X Owen, WI 54460
investigated for 1 of 3 (R3) residents reviewed.On 08/08/25, an allegation of abuse was reported to
by:Facility policy titled, Abuse, Neglect, Mistreatment & Misappropriation of Resident Property Policy & Procedure, with no implemented or reviewed date, states in part: E.
Investigation: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriate of property) are promptly and thoroughly investigated.
Procedure: The investigation is the process used to try to determine what happened.
The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.R3 was admitted to the facility on [DATE] with pertinent diagnoses of mild cognitive impairment of uncertain or unknown etiology, personality disorder, delusional disorders, unspecified psychosis not d/t a substance or known physiological condition, and depression.On 08/08/25 at 2:45 PM, local law enforcement was contacted by R3's sister reporting concerns that R3 was being abused at the facility and R3 does not feel safe.On 08/08/25 at 3:31 PM, law enforcement arrived at facility and informed staff purpose of visit was related to allegation of abuse concerning R3.Surveyor reviewed R3's progress notes and noted:On 08/08/25, R3 stated desire to call 911 for being held prisoner at facility and upset about guardianship and protective placement. At 2:45 PM, facility called local police to inform them that R3 may call and was told that R3's sister had already called to report brother being abused at facility. At 3:10 PM, R1's guardian and county APS SW, DON, and supervisor notified of events and police involvement via email.No additional documentation of investigating allegation of abuse noted.On 10/14/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B regarding incident. DON B stated that R3 and his sister have called the police and reported numerous allegations of abuse that were unfounded. DON B stated that on 08/08/25, R3 had been threatening to call 911 numerous times for being held against his will and had notified the police that R3 might call to report this.
Surveyor asked why this allegation was not reported. DON B stated the facility already knew this allegation was not true due to the multiple prior reports and did not think it should be reported or investigated.
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Clark County Rehabilitation & Living Center W4266 County Highway X Owen, WI 54460
qualified staff for 1 of 3 residents (R1) reviewed.R1's medications were administered by a Certified
Treatment by Certified Nursing Assistants, with no date, states in part: Policy: This facility will comply with all state and federal guidelines related to medication administration in order to ensure the safety of resident.
Nursing assistants may NOT administer any medications or perform any treatments with the following exception as delegated by the nurse: 1.
Nursing assistants can apply prescription and nonprescription topical creams and ointments to UNBROKEN skin during daily cares.
- Nursing assistants can provide oral care with mouthwashes.Facility policy titled, Medication
Administration, with no date, states in part: Policy: Medication administration will adhere to all federal and state regulations.
All medications shall be administered by a licensed nurse or nurse technician per physician order.R1 was admitted to the facility on [DATE] with pertinent diagnoses of anxiety disorder, depression, personality disorder with other symptoms and signs involving cognitive functions and awareness, and unspecified psychosis not due to substance or known physiological condition.R1's physician orders:-Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate) Give 2.5 ml by mouth one time a day for Behavior/agitation/mood.-Valium Oral Tablet 5 MG (Diazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety.On 08/12/25, Director of Nursing (DON) B was made aware of an allegation of abuse regarding R1 and began an investigation.
Interviews were completed with Certified Nursing Assistant (CNA) F, CNA G, and Registered Nurse (RN) E, who were identified in the complaint.
Facility's documentation noted CNA F admitted administering R1's medications using food, ice cream, and a syringe. CNA F stated that someone would hold R1's hand while CNA F held R1's chin and squirted the syringe of medication into R1's mouth.
While CNA F administered R1's medications using physical force, RN E would supervise.Surveyor reviewed CNA F's personnel file and noted no medication administration training completed.On 10/14/25 at 1:10 PM, Surveyor interviewed DON B regarding facility's investigation and the noted medication administration by CNA F. DON B stated it was common practice for the facility to allow CNAs to administer medications while under direct supervision of a nurse.
Surveyor asked DON B if CNAs received additional training or competency evaluation to administer medications. DON B stated, no, that no competency would be needed if the nurse prepares the meds and directly observes the administration by the CNA. DON B further stated that as long as the nurse delegated the medication administration task to the CNA, it was completely acceptable for unlicensed staff to administer medications as long as the RN directly supervised.
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report abuse, neglect, and exploitation.
abuse, neglect, and exploitation and what activities constitute abuse, procedures for reporting and
residents.This is evidenced by:The facility's policy titled Abuse, Neglect, Mistreatment & Misappropriation of resident property policy & procedure, which is not dated, states in part: .Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that.Surveyor reviewed Certified Nursing Assistant (CNA) G, CNA F, and Registered Nurse (RN) E's education for abuse. CNA G completed abuse education on 07/05/23, and RN E completed abuse education on 01/30/24. CNA F did not have recorded abuse education training. On 10/14/25 at 11:50 AM, Surveyor interviewed CNA G about the abuse training. CNA G stated had received abuse education when they first took the CNA class at the facility in 2022.On 10/15/25 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B asking about monitoring for completion of staff education on abuse, neglect and misappropriation at time of hire and annually. DON B stated CNA F's abuse training upon hire was not completed. DON B stated it is the expectation new hire training to be completed before working with residents.
Currently working on a system to ensure all staff are assigned training in the computer and to be completed by 10/31/25. DON B stated understanding there may be staff with a lapse in annual training since trying to put this new system in place. CNA G's training was missed since CNA G was casual. RN E will be scheduled to complete trainings. 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.