Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chippewa Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Consistent PI Care and Skin Monitoring: The facility did not consistently prevent or treat pressure injuries for three residents. One resident at very high risk did not receive timely heel offloading or weekly comprehensive PI measurements, another had heel wounds that were not staged and lacked consistent assessment documentation, and a third had recurrent skin breakdown without current treatment orders, weekly comprehensive skin assessments, or documented provider notification. Staff and DON/ADON interviews confirmed gaps in assessment, staging, and individualized interventions.
Failure to transmit a resident’s death MDS assessment to CMS occurred after the RN/MDS coordinator completed the assessment but did not hit the complete button. The DON and ADON stated only three staff had access to transmit MDS assessments, and they were not aware the assessment needed transmission because it was not completed in the system.
A resident with ESRD and dementia did not receive ongoing assessment and monitoring related to dialysis treatments. Staff documented vital signs and post-dialysis bruit checks, but there were no pre- and post-dialysis weights and no documented communication with the dialysis center. The RN and DON confirmed the facility lacked clear documentation of dialysis-related communication and oversight for the resident’s treatments.
A facility failed to maintain proper infection control when a laundry aide did not sanitize hands between delivering clean linens to residents and left the linen cart uncovered, risking contamination. The Director of Nursing confirmed the expectation for covered carts and hand hygiene, which the aide acknowledged forgetting.
A facility failed to provide written notification of a resident's transfer to the resident's representative and the Ombudsman. The resident, with conditions including metabolic encephalopathy and end-stage renal disease, was hospitalized for behavioral issues and returned to the facility after dialysis. The DON confirmed that no written notice of the transfer was completed or sent.
A facility failed to notify a resident's representative in writing about the bed hold policy upon the resident's transfer to a hospital. The resident, with conditions including metabolic encephalopathy and end-stage renal disease, was hospitalized for urgent dialysis needs. Although the facility provides a Client Handbook with bed hold policy information upon admission, no specific notification was given at the time of transfer.
The facility failed to securely store controlled medications for two residents, as observed during a survey. Two bottles of Lorazepam were found in a refrigerator without being double-locked, despite repeated recommendations from the contracted pharmacy. The ADON acknowledged that one bottle should have been discarded as the resident had been discharged. The DON confirmed the oversight in implementing the pharmacy's recommendations.
Failure to Provide Consistent Pressure Injury Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for three residents reviewed for pressure injuries. The report states that R48 and R47 were cited at actual harm/isolated, and R51 was cited at potential for minimal harm/isolated. The facility also did not complete comprehensive weekly skin assessments with staging, did not obtain physician orders for wound treatments in one case, and did not consistently implement interventions to promote skin integrity and healing. R48 was admitted with diagnoses including hospice/palliative care, Alzheimer’s disease, congestive heart failure, and legal blindness, and was dependent on staff for all ADLs. A Braden score of 9 placed R48 at very high risk for pressure injury development. The record showed a red area to the lower spine on 03/01/26, but the facility did not have weekly assessment measurements of the heel, and the hospice RN was expected to document the pressure injuries. The ADON stated the facility typically would have hospice assess and enter orders to document the pressure injuries three times a week, but this was not done. The DON stated the facility did not complete weekly comprehensive PI assessments and staging. Interventions such as heel floating and an air mattress were not added until after the pressure injuries developed. R47 was admitted with diagnoses including hospice/palliative care, metastatic cancer, tumor lysis syndrome, depression, and chronic kidney disease. The admission MDS documented a BIMS of 15/15 and a Braden score of 17, indicating mild risk. The admission observation report documented no pressure injuries and only a scab on a toe, yet later documentation showed an unstageable left heel pressure ulcer and a right heel wound. Physician orders included heel floating or heel protectors and wound care with measurement and documentation, but the facility did not stage the pressure injuries in the progress notes. The wound management detail report created by the ADON stated the left heel ulcer was observed on 02/25/26, while the ADON and DON told the surveyor the area was present on admission; however, the ADON also stated she did not see the wound on admission and the DON stated she observed it but did not take measurements or document the assessment. The facility did not add heel-floating interventions to the care plan until 03/02/26, and there was no comprehensive assessment for the right heel during the week of 03/03/26. R51 had diagnoses including dementia, dialysis dependence, heart failure, and obesity, and the MDS noted risk for pressure ulcers. The resident had a history of recurrent skin breakdown, including buttock wounds documented in multiple progress notes, but the record did not contain weekly comprehensive skin assessments or current physician orders for skin treatment. The only treatment order found was from 11/25/25 to 01/01/26 for a right buttock wound; no current skin treatment orders were located, and no orders for wound-healing supplements were present. After hospitalization for urosepsis and readmission, the skin assessment documented shearing-type areas on both thighs, but no further skin assessments or progress notes were found after that date. During observation, the surveyor saw an open area on the left inner buttock and dark purple discoloration on the right buttock, while the RN stated the resident sat a lot and was unsure whether there was an order for treatment or who had placed the dressing. The DON and ADON stated the wounds heal and reoccur, but they did not provide documentation of provider notification, individualized interventions, or weekly comprehensive skin assessments.
Failure to Transmit Death MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for one resident who expired in the facility with hospice services was transmitted to the CMS system within 14 days of completion. The resident’s death MDS assessment was completed by the RN who also served as the MDS coordinator, but it was not submitted. Surveyor review found that the facility did not provide its policy related to MDS assessments when requested. During interview, the RN stated she completed the resident’s MDS, while the DON and ADON were responsible for transmitting it. The DON and ADON stated that the MDS coordinator is supposed to hit the complete button when finished, after which it is sent to the NHA, DON, and/or ADON for transmission. The DON also stated that only three staff members had access to transmit MDS assessments and that because the MDS coordinator did not hit complete, the NHA, DON, and ADON were not aware the resident’s MDS needed to be transmitted.
Failure to Monitor Dialysis Resident Before and After Treatments
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident who required dialysis. The facility did not ensure ongoing assessment of the resident’s condition and monitoring for complications before and after dialysis treatments. The resident had diagnoses including dementia and end stage renal disease with dependence on dialysis, and the MDS showed moderate cognitive impairment with a BIMS score of 11/15. The care plan identified the resident’s need for dialysis-related monitoring, including weights before and after dialysis, assessment for swelling and shortness of breath, lab monitoring, and communication with the dialysis facility. Record review showed the resident had orders for dialysis on Monday, Wednesday, and Friday, check and document bruit and thrill of the left forearm fistula, provide supper upon return from dialysis, and monitor vital signs three times per week post dialysis. Survey review found vital signs, temperature, respirations, and blood pressure documented pre and post dialysis, but no pre- and post-dialysis weights and no communication with the dialysis center. Staff interviews confirmed nurses were responsible for vital signs and post-dialysis assessment, but the RN did not know where communication with the dialysis center would be located, and the DON stated there was no documented communication with the new dialysis center related to the resident’s dialysis treatments.
Infection Control Lapse in Linen Delivery
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, impacting five residents. The deficiency was observed when a laundry aide (LA) did not sanitize their hands between delivering clean linens to residents and failed to cover the clean linen cart, leaving it exposed to potential contamination. The LA was seen carrying residents' clothes to the first floor and placing them in dressers and closets without sanitizing hands between rooms. This included entering a room with Enhanced Barrier Precautions (EBP) without following proper hand hygiene protocols. The Director of Nursing (DON) confirmed that the expectation is for the clean linen cart to be covered at all times to prevent contamination and for staff to sanitize their hands in and out of all resident rooms. The LA acknowledged forgetting to cover the cart and admitted that hands should be sanitized between rooms, especially when handling items in an EBP room. This oversight in infection control practices was identified during a survey, highlighting a lapse in adherence to the facility's infection prevention policies.
Failure to Notify Resident's Representative and Ombudsman of Transfer
Penalty
Summary
The facility failed to provide timely written notification of a resident's transfer to the resident's representative and the Ombudsman. This deficiency was identified during an investigation of a resident who was admitted with diagnoses including metabolic encephalopathy, end-stage renal disease, and dependence on renal dialysis. The resident was hospitalized for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. Although the resident was dialyzed and improved, returning to the facility the following day, the facility did not issue a written notice of the transfer to the resident's representative or the Ombudsman. The Director of Nursing confirmed that no written transfer notice was completed or sent.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing about the bed hold policy upon the resident's transfer to a hospital. The resident, who was admitted to the facility with diagnoses including metabolic encephalopathy, end-stage renal disease, and dependence on renal dialysis, was hospitalized for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. The resident was dialyzed and improved, returning to the facility the following day. However, the facility did not provide documentation that the resident's representative was informed of the bed hold policy upon the resident's transfer or within 24 hours of the transfer, as required. The surveyor noted that the facility's Client Handbook, which includes bed hold policy information, is given to residents upon admission, but no specific notification was provided at the time of the transfer.
Failure to Securely Store Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were securely stored, specifically for two residents, R2 and R246. During a survey on January 27, 2025, it was observed that two bottles of Lorazepam 2mg/ml, one for each resident, were stored in a refrigerator in the medication storage room without being double-locked, as required for controlled substances. The Lorazepam bottle for R2 had been opened on December 16, 2024, and the one for R246 on January 1, 2025. The Assistant Director of Nursing (ADON) acknowledged that the Lorazepam bottle for R2 should have been discarded since the resident had been discharged. The surveyor reviewed the facility's medication storage review sheets from the contracted pharmacy, which had repeatedly recommended that Lorazepam concentrate be double-locked in audits conducted from August to November 2024. Despite these recommendations, the facility did not implement the necessary security measures. The Director of Nursing (DON) confirmed that all controlled medications should be double-locked and acknowledged the oversight in monitoring and implementing the pharmacy's recommendations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chippewa Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Home At Chippewa Falls | 1.7 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - Regional Vent Center | 2.9 mi | ★★★★★ | 13 | 0 |
| Oakwood Health Services | 8.1 mi | ★★★★★ | 14 | 0 |
| Grace Lutheran Communities - River Pines | 8.1 mi | ★★★★★ | 3 | 0 |
| Dove Healthcare - West Eau Claire | 8.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chippewa Manor Nursing And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.