A son calls 911. His mother has fallen in her room at an assisted living home outside Wausau, Wisconsin, and he says more than 45 minutes have gone by since he asked the front desk for help. When a deputy arrives, staff explain the situation in one line. The deputy writes it down: two CNAs for the whole building.
As first reported by Wausau Pilot & Review, Marathon County Sheriff’s Office records from Wellington Place at Rib Mountain paint a picture of a facility where caregivers were stretched across too many residents, too many tasks and too many hours.
The newsroom obtained the sheriff’s records under Wisconsin’s open records law. They cover roughly 150 calls logged at the facility’s address from July 2023 into early November 2026. Most were ordinary medical emergencies. Some were not.
That November 2024 fall is one example. The resident was not hurt. But the deputy noted she needed two people to lift her, and she was not wearing her call button. Her only complaint was how long it took.
A few days later, a family member called deputies to say residents had been served half a sandwich for dinner, and some got nothing. Staff said everyone had eaten. The worker on duty explained why she had not picked up the phone: she was putting residents to bed and training two new hires at the same time.
At the end of 2025, a clinic nurse called the sheriff’s office because a Wellington Place worker sounded impaired on the phone. The deputy saw no sign of it. The worker said she was simply tired. She had been working a long stretch of 16-hour shifts.
The records are hardest to read when it comes to a woman with dementia who was placed at the facility by court order this spring. Within days of arriving, staff described her as needing one-on-one attention because she kept trying to leave.
On a single day in late April she generated three calls to the sheriff’s office. In one, she had already walked to a nearby golf course by the time a deputy arrived. In another, staff told a deputy they were keeping her on the property because the county road out front is busy. Hours later, deputies were told she had broken a window trying to get out.
According to the Pilot’s reporting, caregivers in the weeks that followed repeatedly left medication rounds or supper to walk behind her down the road. In June she fell and broke her wrist.
Some relatives turned to law enforcement because they did not know where else to go. In July 2024, a woman reported that her grandmother had two black eyes and bruising on her head. In June 2026, another caller said her grandfather had been found outside for hours shortly after moving in, later fell and hurt his face and knees, and was found on the road. The family took him home.
The company that handles the facility’s dealings with the state, Carriage Healthcare Companies, told the Pilot that residents’ health, safety and well-being remain its highest priorities. It did not answer how many caregivers usually work a shift, or whether 16-hour shifts are routine.
Wisconsin does not set a minimum caregiver-to-resident ratio for this type of facility. The rule only says staff must be on hand “in sufficient numbers” to meet residents’ needs around the clock.
At Bedsore.Law, short staffing is almost always where the harm starts. It is rarely one dramatic failure. It is the call light nobody can answer. The resident who needs two people to stand but only gets one. The meal that comes late or not at all. The aide on hour fourteen who misses the red spot on a heel.
Those small misses add up. Residents who are not turned and checked develop pressure injuries. Residents who are not watched fall. And people with dementia, who cannot always say what hurts, carry the most risk of all.
“Sufficient numbers” is a standard that only works if someone actually counts.
Ask the facility how many caregivers are on your loved one’s floor during the day, at night and on weekends. Then visit at different times and count for yourself. Ask whether your loved one needs one person or two for transfers, and whether that need is written into the care plan.
Check that the call button is within reach and working. Look at heels, hips and the tailbone, or ask a nurse to look with you. If a family member wanders, ask exactly what the plan is when they head for the door, and who is assigned to carry it out.
Write down what you see, with dates. If something feels wrong, it usually is.
If your loved one was injured or developed a bedsore in a nursing home or assisted living facility, Bedsore.Law can help you understand what happened and whether it should have been prevented. Call 844-407-6737 or visit bedsore.law/contact for a free, confidential consultation.
