Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Riverview Health Services during CMS and state inspections, most recent first.
LPNs did not follow expected notification and supervision practices for residents after falls and with a change in condition. A resident with dementia had multiple falls where LPNs assessed and moved the resident without documented RN, DON, or provider contact first; another resident was moved after a wheelchair fall without RN contact; and a third resident with severe cognitive impairment and recurrent hip dislocations had hip swelling and pain documented without notification of an RN, provider, or legal representative.
A resident with Parkinson’s disease and impaired communication was observed without the prescribed jingle bell communication aid while out of the room. Staff later found the bell in the resident’s room, and the resident’s spouse reported the bell is not always kept with the resident even though it is supposed to be used when the resident is not in bed.
An LPN documented a change in a resident’s physical condition and signs of hip discomfort, but did not notify the RN or MD/NP/PA for further evaluation. The resident had severe cognitive impairment, a history of right hip fracture surgery, and later was found at an orthopedic visit to have a dislocated hip; the record did not show further licensed assessment after the initial change was noted.
Failure to provide required bed-hold and transfer notices: two residents were transferred to the hospital by ambulance for a change in condition, but their representatives received Bed Hold Request forms that did not include the written specific reason for transfer and were dated after verbal consent was documented. The facility policy required written bed-hold information at transfer and, for emergency transfers, within 24 hours.
Missing Level II PASARR Screening: A resident admitted with major depressive disorder had a Level I PASARR indicating a Level II review was needed under a short-term hospital discharge exemption, but no Level II PASARR was found in the record. The SSD confirmed the review was not completed and stated the facility did not have a system to ensure PASARR II completion for residents who remained beyond the 30-day window.
A resident with severe dementia, a right hip fracture, and repeated hip dislocations did not have a comprehensive pain management plan that addressed nonverbal pain cues, PAINAD use, agitation, or restlessness. Nursing documented right hip swelling and pain with abductor pillow placement, but there was no documented notification of the provider, RN, or legal representative, and the care plan did not reflect the resident’s recurring dislocations or PRN opioid pain management needs.
The facility did not ensure menus were followed to meet residents' nutritional needs, as meals were substituted without prior approval from the RD. The Dietary Manager reported changing menu items twice weekly due to budgeting concerns, with the RD approving these changes up to 30 days later. This practice could impact the nutritional value of meals for all 38 residents.
The facility failed to ensure proper sanitization and food handling practices, risking foodborne illness for all residents. The dietary staff did not measure the dishwasher's internal temperature, and logs were incomplete. Additionally, a dietary aide did not fully cover his hair or facial hair, violating the facility's policy on staff attire.
A facility failed to ensure proper insulin administration procedures were followed when an RN attempted to administer insulin to a resident without priming the pen. The RN was observed preparing a 22-unit dose for a resident using a Glarigine insulin pen without performing the required safety test. The facility's policy mandates priming the needle with at least 2 units before administration, which the RN did not initially follow.
A resident with dementia and Pick's disease was prescribed risperidone for food aggression, but the facility failed to monitor the specific behaviors the medication was intended to treat. Staff interviews confirmed the absence of these behaviors in monitoring records, leading to an inaccurate assessment of the medication's necessity.
A CNA failed to perform hand hygiene during care for a resident who was incontinent, leading to potential cross-contamination. The CNA did not sanitize hands after removing soiled items and before handling clean items, contrary to the facility's policy. The lapse was attributed to the lack of readily available hand sanitizer.
LPNs failed to notify RN or provider before moving residents after falls and after a change in condition
Penalty
Summary
Nursing staff did not demonstrate the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety for three residents. The report states that LPNs assessed residents after falls, moved them, and documented findings without contacting an RN, DON, or provider first, and that one LPN did not report a change in condition to an RN. The facility policy titled, Fall Prevention and Management Guidelines, required a post-fall assessment and review, including a physical assessment with vital signs, and the Wisconsin LPN Standard of Practice states that LPNs must work under RN supervision or provider direction and report changes in condition to the appropriate person. One resident with dementia and severe cognitive impairment had eight falls after admission. Five of those fall assessments were completed by LPNs and did not include documentation that an RN, DON, or provider was contacted before the resident was moved. The documented fall notes described the resident being found on the floor or beside the bed, being assessed for injuries, having range of motion checks, and being assisted back to bed or off the floor with a mechanical lift, while calls to the clinic were noted as pending or made after the fact. During interview, facility leadership stated the DON was on call 24/7 and that the LPN would collect information and call the DON, and the NHA acknowledged concern about an LPN assessing and moving the resident before contacting an RN, DON, or provider. Another resident with Parkinson's disease and moderate cognitive impairment tipped over in a wheelchair and fell without injury. The record documented that the resident was assisted back to the wheelchair by Hoyer lift and two staff members, but there was no documentation that the LPN contacted an RN before removing the resident from the floor. A third resident with severe cognitive impairment, a prior right hip fracture, and a history of recurrent hip dislocations had slight swelling in the right hip and pain when staff placed the abductor pillow. There was no documentation that the LPN notified a provider, RN, or the resident's legal representative of the change in condition, and there was no further nursing documentation of assessment or notification until the husband later reported that an orthopedic x-ray showed a right hip dislocation and the resident was admitted to the hospital.
Communication Aid Not Kept With Resident
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence, self-determination, and communication by not ensuring the resident’s communication intervention was in place when the resident was out of the room. The resident was admitted with Parkinson’s disease with dyskinesia fluctuation and had a BIMS score of 7/15, with documentation indicating the resident had no speech sometimes understood and sometimes understands. The care plan identified difficulty communicating due to a whispered/soft voice, and the communication intervention stated the resident uses a jingle bell when not in bed. Surveyors observed the resident sitting in the TV lounge without the jingle bell. A Life Enrichment staff member stated the resident had the bell the day before but did not have it at that time. A CNA searched the resident’s room and found the bell between several large containers of snacks, then brought it to the resident. Later, the resident was observed using the bell at the lunch table, and staff responded immediately and spoke with the resident, who became relaxed. The resident’s spouse stated the bell is supposed to be with the resident when not in the room, but it is not always there and is sometimes left in the room.
Failure to Report Significant Change in Resident’s Hip Condition
Penalty
Summary
The facility failed to notify a physician and/or RN about a significant change in a resident’s physical status for one resident, R4, who had diagnoses including anxiety disorder, Parkinson’s disease, dementia, and a right femur/hip fracture history. R4’s MDS showed severe cognitive impairment with a BIMS score of 00, and the care plan noted difficulty communicating and risk for complications related to musculoskeletal problems from the right hip fracture. Facility policy required immediate notification for acute or sudden changes, including marked localized bruising, swelling, or pain over a joint or bone, and the Wisconsin Nurse Practice Act standards cited that LPNs must know what constitutes a change in condition and who to notify. Record review showed that an LPN documented a change in R4’s physical condition during an evening shift but did not notify a physician or RN for further guidance, and there was no further licensed staff assessment documented after that initial note. R4’s husband later reported that during a routine orthopedic follow-up it was discovered that R4 had a dislocated right hip, and he stated R4 had been sitting in the commons area crying when he arrived that morning. He also stated R4 had previously had two right hip dislocations after fracture surgery, both requiring immediate intervention. The record also showed a prior fall at the facility, a later x-ray for difficulty bearing weight that showed no fracture or dislocation, and a subsequent request for another x-ray due to nonverbal cues of pain with the hip.
Failure to Provide Required Bed-Hold and Transfer Notices
Penalty
Summary
The facility did not ensure residents or their representatives received written or verbal consent for bed-hold reserved payment at the time of transfer, and the notice of transfer prior to discharge or transfer did not include the written specific reason for transfer for 2 of 3 residents, R4 and R14. R4 was sent to the hospital via ambulance on 09/19/25 for a change in condition, and R4's representative was given a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 09/22/25 for receiving verbal consent. R14 was sent to the hospital via ambulance on 12/27/2025 for a change in condition, and R14's representative was given a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 12/29/25 for verbal consent. The facility policy titled "Bed Hold Notice," dated 04/23/25, states that the facility is to provide written information to the resident and/or resident representative regarding bed hold practices both well in advance and at the time of a transfer for hospitalization. The policy further states that in the event of an emergency transfer, the facility will provide written notice of the facility's bed-hold policies to the resident and/or resident representative within 24 hours. On 01/26/26 at 2:42 PM, the Business Office Manager stated that the bed hold information and notice of transfer are completed as soon as the Business Office Manager is aware of the transfer or discharge.
Missing Level II PASARR Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident reviewed, R33, within 30 days of admission. R33 was admitted with a diagnosis of major depressive disorder and had an original medication order that included Quetiapine Fumarate 25 mg once daily and Duloxetine HCl 30 mg twice a day. The Quetiapine Fumarate was later discontinued, and Duloxetine HCl was increased to 60 mg in the morning and 30 mg at bedtime. A Level I PASARR screening dated 11/6/25 indicated that R33 had a major mental disorder and had taken psychotropic medications to treat symptoms or behaviors of a major mental disorder, and that a Level II PASARR should be completed under a short-term hospital discharge exemption with a 30-day maximum. Survey review could not locate a Level II PASARR screening for R33, and the Social Services Director confirmed that it was not completed and that the facility did not have a system in place to ensure a PASARR II was completed for residents who stayed past the 30-day window.
Failure to Include Pain Management in Care Plan for Resident with Dementia and Recurrent Hip Dislocations
Penalty
Summary
The facility did not ensure pain management was incorporated into the comprehensive, person-centered care plan for a resident with severe cognitive impairment and a history of right hip fracture and repeated hip dislocations. The resident had a BIMS score of 00/15, an activated healthcare POA, and care plan entries related to difficulty communicating and risk for musculoskeletal complications, but the record did not show a comprehensive pain plan that addressed nonverbal pain indicators, recurring hip dislocations, agitation, restlessness, or the use of the PAINAD tool as part of ongoing pain management. After the resident fell and sustained a right femoral neck fracture, the resident underwent total hip arthroplasty and later had recurring right hip/femoral head dislocations confirmed by x-ray and treated in the ED with external reductions. Nursing documentation on one evening noted slight swelling in the right hip and pain when staff placed the abductor pillow, but there was no documentation that the nurse notified a provider, RN, or the resident’s legal representative about the change in condition. There was also no further nursing documentation of additional assessments or notifications related to the swelling and pain. The resident received scheduled Tylenol and had PRN hydrocodone/acetaminophen ordered for post-surgical pain, but the record showed limited use of the PRN medication despite documented pain scores up to 10. The facility used PAINAD for residents with dementia, and the MAR reflected once-daily PAINAD assessments on alternating shifts, but the care plan did not include interventions for pain assessment and management based on nonverbal cues or for agitation and restlessness, which were documented in skilled nursing notes as recurring behaviors.
Failure to Follow and Approve Menu Changes
Penalty
Summary
The facility failed to ensure that menus were followed to meet the nutritional needs of all 38 residents. Meals were not provided as listed on the menu, and changes were made without consulting the Registered Dietitian (RD) to ensure nutritional adequacy. The Dietary Manager (DM) reported that menu items were being changed approximately twice weekly due to budgeting concerns, substituting planned meals with soup and sandwiches. These substitutions were logged and approved by the RD only when she was on-site monthly, which could be up to 30 days after the changes were made. The RD confirmed that the facility's menus were approved by corporate dietitians and that she was on-site monthly to review and sign off on the log of substituted food items. However, she acknowledged that menu substitutions could impact the nutritional value of meals, as they were not approved prior to being served. This practice had the potential to affect the nutritional needs of all residents, as the substitutions could alter the intended nutritional value of the meals.
Deficiencies in Food Handling and Sanitization Practices
Penalty
Summary
The facility failed to ensure proper sanitization and food handling practices, which could potentially lead to foodborne illness for all 38 residents. The deficiency was observed when the dietary staff did not measure the internal temperature of the dishwasher, a requirement according to the FDA Food Code. The dishwasher's temperature log was incomplete for two consecutive days, and the dietary aide admitted to forgetting to complete it. Additionally, the dietary staff were not using test strips or a data logger to verify that the dishwasher was reaching the necessary sanitization temperatures. Furthermore, the facility did not adhere to its policy regarding staff attire in the kitchen. During an observation, a dietary aide was seen with a hairnet that did not fully cover his hair, and his facial hair was not restrained, contrary to the facility's policy. The dietary manager was unaware of this non-compliance, indicating a lack of oversight in ensuring that all kitchen staff adhered to the required standards for hair restraint.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of insulin, specifically regarding the priming of insulin pens. During an observation, a Registered Nurse (RN) was seen preparing to administer insulin to a resident using a Glarigine insulin pen without performing the necessary safety check. The manufacturer's instructions clearly state that a safety test must be conducted before each injection to ensure the pen and needle are functioning correctly and to remove air bubbles. The RN initially did not prime the needle, stating it was unnecessary unless the pen was new, which contradicts the facility's policy. The incident involved a resident identified as R3, who was prescribed a 22-unit dose of insulin. The RN was stopped by the surveyor before administering the dose and was reminded of the need to prime the needle. Upon questioning, the Director of Nursing (DON) confirmed that the facility's policy requires all nurses to prime the needle with at least 2 units until insulin is visible before dialing the pen to the prescribed dose. The RN's failure to follow this procedure was acknowledged by the DON, who indicated that the RN would be educated on the correct procedure immediately.
Inadequate Monitoring of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring and indication for the use of an antipsychotic medication for one resident. The resident, who was diagnosed with dementia with behavioral disturbance, depression, and Pick's disease, was prescribed risperidone for dementia with behaviors. However, the behavior monitoring did not include the specific behaviors the medication was intended to treat, such as food aggression, which was reported by the resident's daughter and POA as a significant issue prior to admission. The facility's policy requires that psychotropic drugs should only be administered if necessary to treat a specific condition, with documented evidence of the medication's benefit through monitoring and documentation of the resident's response. Interviews with facility staff, including a registered nurse, the director of nursing, and a nurse practitioner, revealed that the resident did not exhibit the behaviors listed in the behavior monitoring records, such as itching, picking at skin, restlessness, and aggression. The nurse practitioner confirmed that the resident was receiving risperidone due to a diagnosis of Pick's disease with food aggression, yet this behavior was not included in the monitoring records. Consequently, the behavior monitoring was not an accurate assessment to determine the necessity of the risperidone medication for the resident.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene during resident care, as observed by a surveyor. Certified Nursing Assistant (CNA) C did not perform hand hygiene after providing peri care to a resident, identified as R10, who was incontinent of bladder and bowel. After removing the resident's soiled bedding and brief, CNA C changed gloves without performing hand hygiene and continued to handle clean items, including applying barrier cream and placing a clean brief on the resident. This action was contrary to the facility's hand hygiene policy, which requires hand hygiene before and after glove use, especially when transitioning from dirty to clean tasks. The surveyor's observation was confirmed through interviews with CNA C and the Director of Nursing (DON) B. CNA C acknowledged the lapse in hand hygiene and attributed it to not having hand sanitizer readily available at the bedside. The DON also confirmed that staff should carry hand sanitizer in their pockets to facilitate hand hygiene at the bedside, emphasizing the importance of performing hand hygiene to prevent cross-contamination and the spread of infection.
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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.
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Nursing homes near Tomahawk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tomahawk Health Services | 2.2 mi | ★★★★★ | 15 | 1 |
| Friendly Village Nursing And Rehab Center | 17.9 mi | ★★★★★ | 6 | 0 |
| Pine Crest Health And Memory Care | 20.3 mi | ★★★★★ | 1 | 0 |
| Rennes Health And Rehab Center-rhinelander | 21.4 mi | ★★★★★ | 8 | 1 |
| Rib Lake Health Services | 25.7 mi | ★★★★★ | 11 | 0 |
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