New Glarus Home

In the surveyor’s words

From the most serious findings on record at New Glarus Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 16, 2026

  Based on observations, interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident. This affected 1 of 3 residents (R2) reviewed for abuse. R1 has a documented history of touching other male residents inappropriately. On 4/27/25, a resident woke to R1 in his room with R1 having his hands in the resident's brief, touching his penis. On 4/28/25, it was reported by a resident that R1's hand was in his crotch. This resident reported that R1 touched his genitals but did not hurt him. R1 was placed on 1:1 (one on one) supervision following these incidents. […]

• Immediate jeopardy, isolatedF700Jun 22, 2022

  Based on observation, interview and record review the facility did not assess the safety risks of using an air mattress in combination with enabler bars affixed to the bed or whether the enabler bar was needed for 7 of 7 sampled residents (R311, R42, R13, R20, R10 R49 and R43) and 6 of 6 supplemental residents (R361, R25, R3, R54, R35 and R1) utilizing enabler bars with an air mattress. R311 was found entrapped in the enabler bar. R42 injured her hand on the enabler bar and R43 had a 4 gap between the mattress and the enabler bar. […]

• Actual harm, isolatedF760Aug 21, 2026

  Based on interview and record review, the facility did not ensure that Residents were free of significant medication errors for 1 (R1) of 6 sampled residents. The facility failed to ensure a prescribed weekly Methotrexate regimen was accurately entered, verified, and administered according to the prescriber's intended frequency for R1. Evidenced by: Review of R1's discharge MDS (minimum data set), with an ARD (Assessment Reference Date) of 07/14/26, indicates R1 was admitted to the facility on [DATE] with diagnoses including arthropathic psoriasis, Type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, polyneuropathy, restrictive lung disease, and recent right conversion total hip arthroplasty with hardware removal performed on 04/09/26. […]

• Actual harm, isolatedF686Dec 5, 2024

  Based on observation, interview, and record review, the facility did not ensure 1 resident (R2) of 2 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R2 was at risk for pressure injury (PI) development. R2 developed a Stage 3 PI to the right ischium. Facility staff did not ensure PI interventions were in place and did not implement appropriate offloading interventions until after the PI was discovered. […]

• Actual harm, isolatedF692Dec 5, 2024

  Based on observation, interview, and record review, the facility did not ensure residents maintain acceptable parameters of nutritional and hydration status for 1 of 1 Residents (R11) reviewed for nutritional status. R11 did not have appropriate interventions put into place to prevent continued weight loss. R11 had a weight loss of 20.6 pounds/12.86% over 2 months and 10 days, indicating a severe weight loss. This is evidenced by: Facility policy titled, Weight Policy, undated, states in part, Goal: To evaluate and meet the nutritional needs of our residents. Objective: Obtain weights as ordered or specified by this policy to monitor changes in weight, weight patterns, and implement appropriate interventions as needed. Procedure: . 3. […]