Problems at The Villa of Greenfield Highlight Challenges Across Wisconsin’s Assisted Living System

In October 2022, Wisconsin’s Department of Health Services finished its investigation of The Villa of Greenfield assisted living facility. Investigators drafted a 97-page report detailing numerous violations, complaints of neglect, police contacts with the facility and more.

The problems at The Villa of Greenfield highlight the challenges facing Wisconsin’s assisted living system, and the risks for the elderly residents.

This report on The Villa of Greenfield is part of a series or articles by Cleo Krejci on the nursing home industry in Wisconsin.

Frequent 9-1-1 Calls Between 2019 and 2022

Between 2019 and 2022, The Villa of Greenfield contacted the police an astonishing 151 times.

The alarming frequency of emergency calls was first noticed by Maggie Sutton, a social worker for the Greenfield Fire Department, in summer 2022. Sutton observed numerous concerning incidents, including cases of neglect, understaffing, and residents in distress. Sutton’s job involves assisting those who frequently call for emergency services.

Sutton would often get to work and see paramedics waiting for her. They would tell her about what happened when they made an overnight visit to the facility.

These frequent meetings with paramedics caused Sutton to visit the facility to assess what was going on. These are some of her observations:

• Smelling feces, urine and marijuana
• Residents slumped over in wheelchairs
• Residents asking for help and not receiving any

Sutton continued to make visits to the facility over the summer of 2022, but she did not see signs of improvement. She discovered that first responders in the area were often overwhelmed with the calls from the facility.

Sutton filed three complaints with the state authorities on her own, but seven other complaints were made by others that year alone. In fact, the facility had 18 other complaints between 2019 and 2022.

Broader Issues in Wisconsin’s Assisted Living System

The situation at The Villa of Greenfield reflects broader issues within Wisconsin’s assisted living system, which has doubled in size over the past two decades but struggles to keep pace with residents’ increasing medical needs. State inspection records reveal many other facilities across Wisconsin having similar problems.

For example:

• A Madison facility had one caregiver for 54 residents, resulting in a $600 fine. It took firefighters nearly an hour to find a caregiver or staff member to help them.
• A Fitchburg facility was fined $1,000 after paramedics found an unresponsive resident in a pool of blood and feces with no staff present. One employee at the facility said they were unable to be in two places at once and had left to get towels and medical records.

Paramedics frequently respond to falls in these facilities due to “no lift” policies that require staff to call 9-1-1 instead of helping residents up. State data shows:

• Nearly 20 percent of Wisconsin ambulance runs in 2022 were for fall-related incidents.
• Fall-related ambulance calls to long-term care facilities increased 28 percent from 2019 to 2022.

The Villa of Greenfield Started to Have Problems in 2020

Timothy Glowinski became the owner of The Villa of Greenfield (formerly Oak Creek retirement facility) in 2016, taking over from his parents. Initially, the facility had few issues, with only one minor citation between 2014 and 2019.

However, problems began to pile up in 2020:

• January 2020: State surveyors found poor hygiene conditions and 22 state code violations but issued no fines.
• Spring 2021: Multiple instances of neglect were reported, including a resident left in a wheelchair for days and another soaked in urine. The state fined the facility $4,450 and mandated improvements in health monitoring procedures.

The manager at the facility, Stephanie Quintero, highlighted many other problems. For instance, the facility struggles to care for residents with complex health needs, which are often too demanding for assisted living. She has overhauled staffing and implemented a more rigorous admissions process to avoid accepting residents requiring care beyond the facility’s capabilities.

Medicaid’s focus on cost-effective placements often results in people with significant needs being placed in assisted living rather than nursing homes.

Glowinski said the problems at the facility have numerous causes, including:

• The COVID-19 pandemic
• Staffing shortages
• Relying on administrators to manage the facility

The facility did have significant staffing challenges, which is not unique to assisted living facilities in the state. For example, 28 percent of caregiver jobs in Wisconsin assisted living facilities were unfilled in 2022. Facilities funded by Medicaid often struggle to compete with retail and fast-food jobs.

How Wisconsin Responded to the Problems at The Villa of Greenfield

In late 2022, a state surveyor investigated 10 complaints at The Villa of Greenfield, including three from Maggie Sutton. The complaints revealed serious issues:

• Allegations of resident mistreatment and neglect, including a January incident where staff allegedly humiliated a resident.
• Multiple residents reported feeling unsafe, with complaints about unresponsive staff and verbal abuse.
• The inspector found 37 code violations, ranging from lack of administrative oversight to failure to protect residents from mistreatment.

In response, the state:

• Issued $15,335 in fines
• Ordered the facility to work with an outside nurse consultant
• Prohibited new resident admissions until conditions improved
• Warned owner Timothy Glowinski that he could lose his license

How Has the Facility Responded to its Problems?

Owner Timothy Glowinski has taken steps to respond to the situation at The Villa, including:

• Raising wages from $10 to $15 an hour
• Working with consulting companies and staffing agencies to improve conditions

Has Your Loved One Been Neglected in Assisted Living? Call PKSD

If you are concerned about your loved one’s treatment at an assisted living facility or nursing home in Wisconsin, PKSD may be able to help. Our Wisconsin nursing home abuse lawyers have obtained millions for victims and families of nursing home residents.

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