Below 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 Tomah Nursing And Rehab during CMS and state inspections, most recent first.
A resident with dementia, prior strokes, and weakness, who required assistance for bed mobility and toileting, reported severe right arm pain after a CNA repositioned her in bed, stating the CNA was rough, pulled her arm, and that she heard a snap. Nursing staff obtained statements from the resident, the CNA, an RN, and an LPN, and the resident was evaluated in the ED, where imaging was negative for fracture and an elbow sprain was suspected. Despite a facility policy requiring comprehensive investigation of alleged abuse or neglect, including interviewing all potential witnesses and others who might have relevant information, the facility did not interview other staff or residents to determine whether similar concerns existed, and no additional investigative documentation was provided, resulting in a finding that the investigation was not thorough.
Improper hand hygiene was observed during dishwashing when a Dietary Aide handled dirty dishes, leftover food, and trash without gloves, then moved to clean kitchen items without washing hands or washing for the required 20 seconds. The aide repeatedly went from dirty to clean tasks, touching clean coffee pots and cups after inadequate hand washing, while the cook and DM acknowledged the concern.
Improper Dumpster and Garbage Disposal: The surveyor observed the main dumpster lid open with a garbage bag, disposable gloves, a hairnet, food wrappers, and cardboard outside the dumpster. The DM stated it was everyone's responsibility to keep the area clean and that all garbage should be inside the dumpster with the lid down. The facility policy required dumpsters to be kept covered at all times and the surrounding area to remain clean and free of debris.
Failure to Thoroughly Investigate Allegation of Neglect: A resident who required 2 staff and a Hoyer lift alleged that staff left her in her wheelchair for hours, did not provide timely care, and left her without her call light in reach. The DON confirmed the concern but did not document staff or resident interviews, did not interview all involved staff or other residents, and the CNA accused of neglect was not interviewed until the surveyor raised the issue. The NHA stated the allegation was not investigated thoroughly.
Baseline Care Plan Missing PTSD Information: A resident admitted with PTSD, borderline personality disorder, CKD stage 5, and dialysis dependence did not have a baseline care plan that included PTSD, triggers, or interventions. The care plan sections for Social Services and additional comments/needs/preferences were blank, and both the SW and DON stated that the resident's PTSD information should have been included.
A resident with CKD stage 5 and dependence on dialysis did not have a clear emergency plan in the care plan, CNA Kardex, or room signage for bleeding from a dialysis catheter. The facility’s dialysis services policy lacked an emergency plan, no emergency supplies were observed in the room, and CNAs reported they had not received education on dialysis care. Staff gave inconsistent responses about what to do if bleeding occurred, with the LPN, DON, and RN describing different actions.
Failure to provide trauma-informed care for a resident with PTSD. A cognitively intact resident with PTSD, borderline personality disorder, CKD stage 5, and dialysis dependence had a trauma assessment that documented multiple traumatic experiences, but the care plan did not list PTSD, triggers, goals, or interventions. Interviews with CNA, LPN, SW, DON, NHA, and RN staff confirmed the resident’s PTSD care plan was incomplete and that the trauma assessment did not include additional questions about the resident’s trauma history or triggers.
A resident with anxiety and cognitive impairment was prescribed buspirone for anxiety, but the order was never entered into the physician orders or MAR and the medication was not administered. The psych provider, ADON, and DON gave conflicting accounts about the faxed order and its processing, and the facility’s records showed the order was uploaded but never initiated.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found 8 medication errors in 25 opportunities, for an error rate of 16%. An RN gave a resident several meds outside the ordered time window and administered the wrong dose of hydroxyzine. Facility policy required meds to be given within one hour of the designated time and in the exact ordered dose.
Failure to Report Allegations of Abuse and Neglect Timely: A resident with a care plan requiring 2 staff and a hoyer lift reported being left in a wheelchair for hours, left wet, without colostomy care, and without a call light; staff and the DON recognized the concern as possible neglect, but it was not reported to the State Survey Agency. In a separate grievance, a cognitively intact resident with PTSD, borderline personality disorder, CKD stage 5, and dialysis dependence reported staff tried to shove her into a van and caused increased pain; the DON agreed it could be abuse, but it also was not reported to the State Survey Agency within the required timeframe.
Several residents with impaired mobility or cognition were found with their beds in direct contact with or very close to baseboard heaters, some of which were measured at dangerously high temperatures. One resident sustained second-degree burns after falling and becoming trapped against a heater. Staff interviews revealed inconsistent knowledge about safe distances and no system was in place to monitor heater temperatures or ensure safe bed placement, resulting in a serious deficiency.
A resident with multiple chronic conditions had a physician order for a urinalysis due to ongoing urinary symptoms. Nursing staff were unable to collect the urine sample before the lab closed and did not obtain further instructions from the provider or escalate the issue, resulting in the ordered test not being completed as required.
The facility did not maintain an effective infection prevention and control program during COVID-19 and gastroenteritis outbreaks, including incomplete and inconsistent line listings, lack of routine symptom screening, failure to document isolation removal dates, unrecognized outbreaks, and inadequate documentation of staff illness and return-to-work status.
A resident reported that a CNA was consistently rough during care, causing bruises and making derogatory remarks. Although the administrator was aware of the allegation, it was not reported to the state survey agency or law enforcement as required by policy and regulation.
Two residents reported separate incidents of alleged abuse and mistreatment by a CNA, including physical roughness, inappropriate gestures, and derogatory comments. The facility did not fully investigate these allegations, as required by its own abuse prevention policy, by failing to interview all relevant staff and residents or provide staff education on abuse and mistreatment.
A resident with chronic venous hypertension and bilateral lower extremity ulcers did not consistently receive physician-ordered wound care treatments, as evidenced by multiple missed and unsigned dressing changes on the TAR. Nursing staff acknowledged that dressing changes were sometimes missed, often due to staffing issues, and the DON confirmed that unsigned entries indicated treatments were not completed.
A resident with a stage 3 pressure ulcer and multiple comorbidities did not consistently receive physician-ordered wound care treatments, as evidenced by multiple unsigned entries on the treatment administration record. Nursing staff and the DON confirmed that dressing changes were sometimes missed, often due to staffing issues, and facility policy requiring adherence to treatment orders was not consistently followed.
A resident at risk for falls did not have new care planned interventions implemented after a fall. Observations showed the bed was in a high position and the fall mat was not placed correctly. Staff interviews revealed a lack of awareness and adherence to the care plan, with the DON confirming the interventions should have been followed.
The facility was found to have several deficiencies related to food safety and sanitation practices, affecting all 49 residents. Kitchen staff failed to maintain proper hygiene, with issues such as unrestrained facial hair and improper hand hygiene when handling dishes. Food storage practices were inadequate, with unlabeled expiration dates and improper equipment storage. Additionally, a thermometer was not allowed to air dry before use, and food trays were transported uncovered, contrary to policy.
The facility failed to provide adequate supervision and adhere to smoking and feeding policies, leading to potential safety hazards. Several residents maintained their own smoking materials and smoked in non-designated areas without supervision, contrary to facility policy. Additionally, a resident at risk for aspiration was not provided with necessary feeding precautions, and another resident requiring meal assistance was left unattended, highlighting deficiencies in care plan adherence.
The facility failed to provide necessary care and assistance to residents unable to perform activities of daily living. Three residents did not receive routine weekly showers, and documentation was incomplete. Another resident, dependent on staff for eating, missed a meal due to lack of assistance. Staff interviews revealed a lack of awareness and coordination in providing necessary care.
A resident with cognitive and physical impairments was not treated with dignity during meal assistance, as a CNA stood over them instead of sitting beside them, contrary to facility policy. The Nursing Home Administrator was aware of the expectation for staff to sit beside residents during such assistance.
A resident with a pressure injury on the left heel did not receive proper wound care due to the failure of the ADON to perform hand hygiene between glove changes and after handling soiled dressings. Despite the facility's policy requiring handwashing during such procedures, the ADON acknowledged not following these protocols, which was confirmed by the DON and Regional Care Director.
A facility failed to adhere to infection control protocols for a resident on Enhanced Barrier Precautions (EBP). Staff did not wear gowns during high-contact care and neglected to sanitize a Hoyer lift after use, contrary to facility policy. The resident had multiple health issues, including sepsis and pressure ulcers, necessitating strict infection control measures. The deficiency was identified when a CNA attempted to use the unsanitized lift on another resident, prompting surveyor intervention.
Failure to Thoroughly Investigate Allegation of Rough Handling and Injury
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of rough handling and potential abuse involving one resident. The resident, who had dementia with behavioral disturbance, multiple cerebral infarctions, and weakness, required assistance of one staff member for bed mobility and toileting. On the date of the incident, a CNA assisted the resident with incontinence care and repositioning in bed. After being turned, the resident complained of right arm pain, reported hearing a snap, and rated the pain as 10/10. The resident told nursing staff that the CNA was rough and that the CNA pulled her arm while rolling her, causing pain. Following the incident, the CNA reported the resident’s complaint to an RN, who assessed the resident and noted that the resident was tearful and in significant pain when her elbow was touched. The CNA stated she had held the resident’s hand and hip to roll her and that the resident then said her arm hurt. The RN documented that the CNA acknowledged using the resident’s right arm to pull her toward the window to complete cares, and that the resident reported hearing a pop at the time the pain started. Another nurse (an LPN) also spoke with the resident and confirmed that the resident said the CNA was rough and had pulled her arm while rolling her, after which the resident heard a snap and experienced severe pain. EMS transported the resident to the ED, where the physician documented right elbow tenderness, a negative radiograph for fracture, and suspected a right elbow sprain. The facility’s abuse prevention policy requires that all alleged violations be investigated thoroughly, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and determining whether abuse or neglect occurred, its extent, and cause. Although the facility obtained statements from the resident, the CNA, the RN, and the LPN, there was no further documentation of the investigation beyond these statements and the ED report. The Nursing Home Administrator acknowledged that the facility did not interview other staff or other residents to determine whether there were additional concerns or a broader scope to the issue. Surveyors concluded that the facility failed to interview other residents and did not complete a thorough investigation of the allegation, resulting in the cited deficiency.
Improper Hand Hygiene During Dishwashing
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During observation of the dishwashing process, a Dietary Aide was assigned to the dirty dishes while another staff member was assigned to the clean dishes. The Dietary Aide handled leftover food and dirty napkins without gloves and moved from the dirty dish area to other areas of the kitchen without washing hands. The aide was also observed going from dirty dishes to emptying the garbage can and then touching clean coffee pots and multiple clean cups. The Dietary Aide was observed multiple times washing hands for less than 20 seconds before touching clean dishes. The surveyor met with the Dietary Aide and the cook, and both indicated understanding of the concern. Later, the Dietary Manager stated that staff should always wash their hands when going from dirty dishes to clean and should wash for at least 20 seconds, and indicated understanding of the concern.
Improper Dumpster and Garbage Disposal
Penalty
Summary
The facility did not ensure that garbage and refuse was disposed of properly. During the initial walk-through of the kitchen, the surveyor observed the main dumpster with its lid open and found a garbage bag, multiple disposable gloves, a hairnet, food wrappers, and cardboard outside of the dumpster. The Dietary Manager observed the condition of the dumpster area with the surveyor and stated that it was everyone's responsibility to keep the area around the dumpster clean and that all garbage should be inside the dumpster with the lid down. The facility policy stated that dumpsters are to be kept covered at all times and that the area around the dumpster is to be kept clean and free of debris, foul odors, and pests.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect made by R10, a resident admitted with diagnoses including weakness and diabetes mellitus with diabetic neuropathy. R10’s care plan required two staff and a Hoyer lift for transfers. During a screening interview, R10 stated staff left her in her wheelchair for long periods even when she asked to be laid down in bed, said staff told her there was only one staff working and they were too busy, and reported that she had once been left in her chair for 12 hours. She was observed crying and shielding her face while making these statements. The grievance record showed that on 12/24/25 a concern was raised that R10 was still in her chair at midnight, needed her colostomy bag changed due to leaking, and may not have been cared for by the assigned PM aide/Activity Director/CNA. The facility documented that the grievance was confirmed and that R10 had been in her wheelchair at midnight; the CNA assigned stated R10 refused to go to bed or allow cares, and R10 said she may have told the CNA she did not want to lay down when approached. The only documented corrective action was education with the CNA to reapproach the resident after refusal of cares. Further interviews showed that R10 was found awake, tearful, upset, incontinent, with her call light not in reach, and still in her wheelchair wearing day clothes after supper. DON B stated she talked to R10 and some staff from the PM and night shifts, but did not document the interviews, did not interview other residents, and did not interview all staff working during the period. LPN Q stated the situation could be an allegation of abuse/neglect and that she instructed CNA O to call the DON immediately. CNA O stated she reported the allegation of neglect against CNA P right away. CNA P stated she was never interviewed by the DON until the surveyor brought the issue to her attention. The NHA stated the allegation was not investigated thoroughly and that the DON should have interviewed residents and all staff who worked that shift and documented the interviews.
Baseline Care Plan Missing PTSD Information
Penalty
Summary
The facility did not ensure that each resident had a baseline care plan developed and implemented within 48 hours of admission with the instructions needed to provide effective and person-centered care. For one resident, R5, the baseline care plan dated 12/15/25 and signed by R5 on 12/17/25 did not include pertinent diagnoses, including PTSD, and did not identify triggers or interventions. The sections of the baseline care plan for Social Services and additional comments/needs/preferences were blank. R5 was admitted with diagnoses that included PTSD, borderline personality disorder, chronic kidney disease stage 5, and dependence on dialysis. The most recent MDS dated 1/12/26 indicated a BIMS score of 14 out of 15, showing that R5 was cognitively intact. During interviews on 1/12/26, the SW stated that R5 should have a care plan for PTSD and that nursing was responsible for care plans. The DON also stated that R5's PTSD, triggers, and interventions should have been on the baseline care plan.
Dialysis Bleeding Emergency Plan Not Known by Staff
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis, because facility staff were not fluent in the emergency plan for a resident bleeding from a dialysis access site. The facility’s dialysis services policy, last reviewed in 1/2025, did not include an emergency plan. The resident involved, R5, was admitted with diagnoses including PTSD, borderline personality disorder, chronic kidney disease stage 5, and dependence on dialysis. R5’s most recent MDS dated 1/12/26 showed a BIMS score of 14 out of 15, indicating cognitive intactness. R5’s care plan initiated on 12/16/25 did not include steps for staff to take if R5 was bleeding from a dialysis catheter, and the CNA Kardex also did not include such steps. Surveyors observed that R5’s room had no signage indicating the resident had a dialysis catheter or what to do in an emergency if bleeding occurred, and no emergency equipment or supplies were observed in the room. During interviews, CNAs stated they had not received education from the facility on how to care for a resident on dialysis and gave inconsistent responses about what to do if R5 bled from the dialysis catheter. The LPN stated pressure should be applied and the resident sent to the ER, while the DON and RN stated staff should apply pressure and update the MD; the RN also stated CNAs should get the nurse. The RN stated the facility relied on site monitoring on every shift, and no education was provided to the surveyor.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility did not ensure that a resident with PTSD received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. The report states that the resident had diagnoses including PTSD, borderline personality disorder, chronic kidney disease stage 5, and dependence on dialysis, and that the resident’s most recent MDS showed a BIMS score of 14 out of 15, indicating cognitive intactness. The facility’s policy required identifying trauma history, triggers, and trigger-specific interventions and adding them to the care plan. The resident’s trauma-informed care observation documented multiple traumatic experiences, including personally witnessing a natural disaster and personally experiencing a life-threatening illness or injury, a physical assault, and a sexual assault. During interview, the resident described additional trauma history, including an assault in 1990 that caused a broken neck and near-death situation, the deaths of the resident’s brother, mother, father, and cat, and stated that triggers included loss of special people, kidney failure, and hearing helicopters. However, the resident’s care plan did not list PTSD as a problem and contained no goals, triggers, or interventions. Staff interviews showed that CNA staff were aware that triggers and interventions should be on the care plan, but CNA G had not reviewed the care plan and confirmed it did not contain PTSD triggers or interventions. LPN F also reviewed the care plan and could not find any PTSD triggers or interventions. The social worker stated that a trauma assessment was completed, but it consisted of yes-or-no questions and no additional questions about trauma, triggers, or interventions were asked. The DON, NHA, and regional nurse stated that a resident admitted with PTSD should have a trauma-informed care assessment and a PTSD care plan, and the DON stated the resident should have a care plan for PTSD.
Failure to Process and Administer Ordered Buspirone
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for one resident, R13. R13 was admitted with diagnoses including anxiety disorder, depression, and cognitive impairment, and had a BIMS score of 11 indicating moderate cognitive impairment. A psych initial evaluation documented that R13 reported anxiety with restlessness and was started on buspirone 5 mg three times daily for anxiety. Although the buspirone order was documented in the psych evaluation and later in a psych follow-up note and physician order form, the medication was not entered into the resident’s physician orders or MAR for November or December 2025. The report states that the order was faxed but never processed into the electronic physician orders or MAR, and the resident did not receive buspirone as ordered. The facility’s own policy stated that the licensed nurse receiving an order is responsible for placing it in the EHR, MAR/TAR, ordering the medication from pharmacy, and communicating order specifics to appropriate departments. Interviews with NP I, ADON J, and DON B showed confusion about the order’s transmission and processing. NP I stated she believed the order had been received and entered, while ADON J stated she discussed the medication change with NP I, obtained consent from R13, but never received the faxed order to enter it into the system. DON B stated the facility should have followed the provider order and should have notified NP I when the faxed order was not received. The record also showed that the buspirone order was uploaded into documents but never entered into the physician orders or MAR, and a progress note later stated that the buspirone order was never initiated.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility did not ensure it was free of medication error rates of 5% or greater. Surveyors identified 8 medication errors in 25 opportunities, affecting 1 resident out of a sample of 5 residents observed for medication administration, resulting in an error rate of 16%. During observation on 1/8/26 at 4:10 PM, RN N administered medications to R50 at a time outside the ordered 6:00 PM-10:00 PM medication window, including Klor-Con 20 mEq, levetiracetam 1000 mg, tamsulosin hydrochloride 0.4 mg, and hydroxyzine hydrochloride 25 mg. R50 was also given hydroxyzine hydrochloride 25 mg as 1/2 tablet instead of the ordered 1 tablet. The facility policy stated that medications must be passed within one hour on either side of the designated time and that the exact number of tablets or capsules ordered must be given. On 1/12/26, RN H stated that giving medications at the wrong time and giving the wrong dose would be medication errors.
Failure to Report Allegations of Abuse and Neglect Timely
Penalty
Summary
The facility failed to report alleged abuse and neglect immediately, and not later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency for two incidents. The deficiency involved one resident who was alert and cooperative, had diagnoses including weakness and diabetes mellitus with diabetic neuropathy, and whose care plan required 2 staff and a hoyer lift for transfers. During a screening interview, the resident stated staff left her in her wheelchair for long periods, including one time for 12 hours, even when she asked to be put in bed, and said she had reported these events to staff without anything happening. For the first incident, a grievance form documented that the resident was still in her wheelchair at midnight, needed her colostomy bag changed because it was leaking, and was believed to have been left by the assigned PM aide/activity director/CNA. The resident’s nurse note stated she was found awake in her wheelchair during midnight rounds, was tearful and upset, said evening staff left her alone in her wheelchair since supper, and requested a report be filed. The DON stated she was called around 12:30 AM and later spoke with the resident and some staff, but did not document interviews, did not interview other residents, did not interview all staff on duty, and did not report the allegation to the State Survey Agency. The LPN stated the concern that a staff member did not provide care and left the resident without a call light for 6 hours could be an allegation of neglect and that she told CNA O to call the DON right away. CNA O stated she found the resident crying, incontinent, with soaked clothing, an exploded colostomy bag on her clothing, and no call light within reach, and that she reported the allegation of neglect to the LPN and DON right away. For the second incident, a resident with PTSD, borderline personality disorder, chronic kidney disease stage 5, dependence on dialysis, and a BIMS score of 14/15 submitted a grievance describing that staff tried to shove her into a medical van for dialysis, causing increased pain and preventing her from going to dialysis that day. The resident told the surveyor that three staff were trying to shove her into the van and that their actions caused increased pain. The DON stated she became aware of the grievance the afternoon it was received, acknowledged that the resident’s report could be considered an allegation of abuse, and confirmed it was not reported to the State Survey Agency. The NHA later stated the allegation should have been reported to the State Survey Agency and that since becoming aware, the facility had submitted the allegation.
Failure to Prevent Burns Due to Inadequate Monitoring and Unsafe Placement of Baseboard Heaters
Penalty
Summary
Surveyors identified that the facility failed to ensure resident environments were free from accident hazards by not having a system in place to monitor the surface temperature of baseboard heaters and by failing to maintain safe distances between resident beds and these heaters. Multiple residents with impaired mobility and/or cognition were found to have their beds either touching or within a few inches of baseboard heaters, some of which were measured at temperatures significantly above the 125°F threshold considered acceptable for LTC settings. Manufacturer documentation and state guidance both indicated that objects, including beds, should be kept at least 12 inches away from baseboard heaters to prevent burns and other injuries. One resident with severe cognitive and mobility impairments fell out of bed and became trapped between the bed and the wall, coming into prolonged contact with a baseboard heater and sustaining partial thickness (second-degree) burns. This resident had a history of falls, impaired sensation, and required assistance for mobility. The incident occurred when the resident rolled out of bed, and the heater's surface temperature was not being monitored or logged by facility staff. Other residents with similar risk factors were also observed to have beds in direct contact with or very close to baseboard heaters, with measured surface temperatures ranging from 127°F to 169°F. Some residents reported that the heaters were extremely hot to the touch, and staff interviews revealed inconsistent knowledge about required safe distances between beds and heaters. The facility did not have policies or procedures in place to ensure regular monitoring of heater surface temperatures or to ensure that beds and other combustible materials were kept at safe distances from heaters. Staff were not uniformly aware of the risks or the manufacturer's recommendations, and there was no evidence of routine audits or temperature checks prior to the survey. The lack of a systematic approach to identifying and mitigating these hazards resulted in at least one resident sustaining burns and placed other residents at risk for serious harm.
Removal Plan
- Bed was moved away from the heat register for affected resident (R3).
- A larger 42-inch bed was provided to R3 to prevent future falls.
- The baseboard heater in R3's room was replaced with a newer style heater as a precaution.
- R7's bed was moved to the other side of the room away from the heat register.
- Care plans were updated to include instructions to keep beds away from heat registers.
- Re-education of all staff was provided regarding keeping residents and beds away from heaters.
- Ambassador rounds were completed to ensure all beds were moved away from registers.
- Audit of rooms was conducted to check register temperatures with an infrared thermometer.
- All resident rooms were checked and beds closer than 1-2 feet from registers were adjusted.
- Care profiles were updated for staff to check bed/personal item placement in relation to registers.
- All room heat registers had their temperature checked and confirmed to be within manufacturer specifications.
- Rooms were rechecked for bed placement away from registers.
- One resident was moved to another room when their room could not be rearranged to meet safety requirements.
- Audits were created to monitor heat register temperature, room temperature, and corrections for heat registers.
- Audit protocol was created for placement of beds away from registers.
- Random temperature audits of registers to be completed, with all audits reviewed at QAPI.
- NHA or designee to complete bed positioning audits at the same frequency as temperature audits, with review at QAPI.
- QAPI meeting held to review plan, root cause, and ensure compliance with F689.
- Baseboard Heat Registry Protocol implemented: Residents and beds to maintain a safe distance from baseboard heat registers; recliners positioned safely; concerns reported to Maintenance Lead or Administrator for prompt follow-up.
Failure to Obtain Ordered Urinalysis and Notify Provider
Penalty
Summary
Nursing personnel failed to follow physician orders for a resident who was admitted with multiple diagnoses, including Alzheimer's disease, dementia, hypertension, and chronic pain. The facility received an order to obtain a urinalysis (UA) for the resident after family members expressed concerns about urinary symptoms. While a complete blood count (CBC) was obtained and sent to the lab, staff were unable to collect a urine specimen before the lab closed for the weekend. The resident's power of attorney was notified, and fluids were encouraged, but the UA was not obtained as ordered. The facility did not have a policy addressing the process for following physician orders or steps to take if orders could not be completed. Nursing staff communicated the inability to obtain the UA to the nurse practitioner via email but did not receive a response or further instructions. There was no documented follow-up with the provider or escalation to an on-call provider as expected. Interviews with facility staff and consultants confirmed that the standard practice would be to contact the provider for further direction if an order could not be completed, but this was not done in this case.
Failure to Maintain Infection Prevention and Control During COVID-19 and Gastroenteritis Outbreaks
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies during outbreaks of COVID-19 and gastroenteritis. Surveyors found that the facility did not complete line listings contemporaneously, with discrepancies between comprehensive and COVID-19-specific lists, and missing or inconsistent information such as resident names, dates of onset, and dates of removal from precautions. The facility also failed to document why testing was conducted when residents were asymptomatic and did not track residents with symptoms, only those who tested positive. Routine screening for COVID-19 symptoms among residents was not performed daily, nor was it increased to every shift during the outbreak as required. The facility did not document when residents were removed from isolation precautions after a positive COVID-19 test, and there was confusion among staff regarding the criteria for discontinuing precautions. Additionally, the facility did not recognize a gastroenteritis outbreak among staff, despite multiple staff members exhibiting gastrointestinal symptoms within a short timeframe, and failed to implement outbreak control measures. Documentation for staff with gastroenteritis symptoms was incomplete, with missing last symptom dates and return-to-work dates, resulting in staff returning to work too soon after illness. In several cases, staff did not remain out of work for the required period following symptom resolution, and there was no clear process for determining when it was safe for staff to return. These failures were confirmed through interviews with the DON and Regional Clinical Director, who were unable to provide consistent explanations for the discrepancies and lapses in infection control practices.
Failure to Report Alleged Abuse and Rough Treatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the appropriate authorities, including the State Survey Agency, as required by both facility policy and state law. Specifically, a grievance form documented that a resident reported a Certified Nursing Assistant (CNA) was consistently rough during care, resulting in bruises, and made derogatory comments about the resident's weight. The facility's policy mandates that such allegations be reported immediately, but this was not followed in this instance. During an interview, the Nursing Home Administrator confirmed awareness of the resident's allegations but admitted that the incident was not reported to the state survey agency or law enforcement, as required. The failure to report the allegation of rough treatment and resulting bruising constituted noncompliance with both internal policy and regulatory requirements for timely reporting of suspected abuse.
Failure to Thoroughly Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for two residents. In the first instance, a resident reported that a Certified Nursing Assistant (CNA) made an obscene gesture and expressed feeling unsafe with that CNA present. The facility's own Misconduct Incident Report documented the allegation, but the Nursing Home Administrator confirmed that the investigation was incomplete, as other staff who worked with the CNA were not interviewed and staff were not educated regarding abuse and mistreatment as required by the facility's Abuse Prevention Program. In the second instance, another resident alleged that the same CNA was rough during care, resulting in bruises, and made derogatory comments about the resident's weight. The facility's grievance form documented these concerns, but again, the Nursing Home Administrator acknowledged that the investigation was not fully conducted. Specifically, other residents and staff were not interviewed, and further education on abuse and mistreatment was not provided to staff, contrary to the facility's policy for investigating such allegations.
Failure to Complete Physician-Ordered Wound Care for Venous Stasis Ulcers
Penalty
Summary
A deficiency occurred when a resident with chronic venous hypertension and bilateral lower extremity ulcers did not receive wound care treatments as ordered by the physician. The prescribed treatment included cleansing the wounds, applying skin prep, Medihoney, Calcium Alginate, ABD pads, kerlix gauze, and ACE wrap, to be changed daily and as needed. Review of the Treatment Administration Records (TAR) for February and March revealed multiple dates where the dressing changes were not signed off as completed, indicating the treatments were not performed as ordered. Interviews with nursing staff confirmed awareness that dressing changes were sometimes missed, with staff citing staffing challenges as a contributing factor. The DON confirmed that unsigned treatments on the TAR indicated they were not completed, and was only able to account for one of the missed dates. Facility policy required treatments to be provided according to physician orders, but this was not consistently followed for the resident in question.
Failure to Consistently Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of a stage 3 pressure ulcer on the left heel, chronic venous hypertension with ulcers, myocardial infarction, and type 2 diabetes mellitus did not consistently receive pressure ulcer treatments as ordered by the physician. The treatment orders specified daily wound care, including cleansing with normal saline, application of skin prep and Medihoney, and dressing with ABD pad, Kerlix gauze, and ACE wrap. Review of the Treatment Administration Records (TAR) for February and March revealed multiple dates where the dressing change was not signed off as completed, indicating the treatments were not performed as ordered. Interviews with nursing staff confirmed awareness that dressing changes were sometimes missed, with staff citing staffing challenges as a contributing factor. The Director of Nursing acknowledged that unsigned treatments on the TAR indicated they were not completed and was only able to confirm completion for one of the missed dates. Facility policy required adherence to physician orders for pressure ulcer care, but this was not consistently followed, resulting in the deficiency.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement new care planned fall interventions for a resident, R3, who was at risk for falls. R3 had a fall on 09/16/24, and the facility's care plan included interventions such as placing the bed in a low position and using a fall mat next to the bed. However, during observations on 11/11/24, the surveyor noted that R3's bed was in a high position, and the fall mat was not placed next to the bed but was instead across the room. This indicates that the facility did not follow through with the planned interventions to prevent further falls. Interviews with staff, including CNAs and the Director of Nursing, revealed a lack of awareness and adherence to the care plan interventions. CNA D was unaware that R3's bed was in a high position and that the fall mat was not correctly placed. Both CNA D and CNA E acknowledged that the expectation was for the fall mat to be on the floor next to the bed when R3 was in bed. The Director of Nursing confirmed that the interventions should have been implemented as planned, indicating a failure in ensuring staff compliance with the care plan to prevent accidents.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food safety and sanitation practices, which had the potential to affect all 49 residents. Observations revealed that kitchen staff did not maintain proper personal hygiene, as evidenced by staff members with facial hair not wearing beard covers as required by the facility's policy. Additionally, there was a lack of awareness among staff and supervisors regarding the necessity of beard restraints, indicating a gap in training and policy enforcement. Further deficiencies were noted in the handling and storage of dishes. A staff member was observed moving between handling dirty and clean dishes without performing proper hand hygiene, despite changing gloves. The staff member's uniform, which was visibly soiled, came into contact with clean dishes, posing a risk of contamination. The facility's policy did not address the use of aprons to prevent such contamination, highlighting a need for clearer guidelines and adherence to hygiene protocols. The storage of food and equipment also presented issues. Bulk cereals were stored in bins without proper labeling of expiration dates, and scoops were left submerged in the food, increasing the risk of contamination. A meat slicer was left uncovered on a counter, which could lead to contamination from dust or food particles. Additionally, a staff member did not allow a thermometer to air dry after using an alcohol wipe before inserting it into beverages, potentially contaminating the drinks. Lastly, trays of food were observed being transported uncovered through hallways, contrary to the facility's policy, which requires all food to be covered during transport.
Inadequate Supervision and Policy Adherence in Smoking and Feeding Practices
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to smoking policies for several residents, leading to potential safety hazards. Residents R22, R43, R39, and R32 were observed maintaining their own smoking materials, contrary to the facility's smoking policy, which mandates that all smoking materials be stored by staff. These residents were also seen smoking in non-designated areas without supervision, increasing the risk of accidents. The facility's policy requires that all residents, regardless of their assessed smoking safety, be supervised while smoking, which was not adhered to in these instances. Additionally, the facility did not implement feeding precautions for R43, who was at risk for aspiration. Despite hospital discharge instructions and a care plan that included specific feeding precautions, R43 was observed eating meals without staff supervision or assistance. The care plan was not updated to reflect the necessary precautions, and staff failed to check in with R43 during meals, which could have led to aspiration risks. Furthermore, R1, who requires assistance during meals due to multiple sclerosis and dysphagia, was not provided with the necessary meal assistance. The care plan specified that R1 should be assisted with meals to prevent choking or aspiration, yet staff were observed not assisting R1 during a meal. This lack of supervision and assistance during meals for R1 and R43 highlights a significant deficiency in the facility's adherence to care plans and safety protocols.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to ensure that four residents who were unable to perform activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene. Specifically, residents R48, R16, and R5 did not receive routine weekly showers as required. Documentation provided by the Regional Care Director (RCD) was incomplete, missing several weeks of shower review sheets for these residents. Interviews with the residents revealed that they were either unaware of missing showers or unsure of their shower schedule. The facility's policy required documentation of either the provision or refusal of showers, but this was not consistently followed. Additionally, the facility did not provide adequate nutritional assistance to resident R2, who is dependent on staff for eating due to severe cognitive impairment and other health issues. On the day of observation, R2's breakfast tray remained untouched on a cart in the dining room, and staff did not offer the meal to R2 in their room or provide any substitutes. Despite being up since early morning, R2 was not brought to the dining room or offered assistance with eating, leading to a missed meal. Interviews with staff, including the Nursing Home Administrator and Director of Nursing, revealed a lack of awareness and coordination in ensuring R2 received meals. The staff acknowledged that R2 needed supervision and assistance with meals but failed to provide it. The facility's failure to adhere to its policies and provide necessary care and assistance resulted in deficiencies in maintaining the residents' hygiene and nutrition.
Resident Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, specifically in the context of assisting with meals. A resident, identified as R34, who was admitted with diagnoses including weakness, cognitive communication deficit, and diabetes, required substantial to maximum assistance with eating. During an observation, a Certified Nursing Assistant (CNA) was seen standing over R34 while assisting them with their noon meal, rather than sitting beside them as expected by the facility's policy. This action was contrary to the facility's policy on resident rights, which emphasizes a dignified existence and self-determination for residents. The Nursing Home Administrator acknowledged the expectation for staff to sit beside residents during meal assistance and had addressed the issue with the CNA involved.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident identified as high risk for pressure injury development. The resident, who was admitted with conditions including neutropenia, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and cognitive impairment, had a care plan addressing a pressure injury on the left heel. The care plan included interventions such as using pressure-reducing boots and monitoring for signs of infection. However, during an observation, the Assistant Director of Nursing (ADON) did not perform hand hygiene between glove changes and after handling soiled dressings while conducting wound care for the resident. The ADON was observed removing soiled dressings and applying new ones without washing hands between glove changes, which is against the facility's hand hygiene policy. This policy requires handwashing after contamination with body fluids, after removing gloves, and before and after nursing procedures. The ADON acknowledged the failure to perform hand hygiene when interviewed by the surveyor. The Director of Nursing and the Regional Care Director confirmed that the expectation is to conduct hand hygiene to prevent potential wound infections.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the staff during the care of a resident on Enhanced Barrier Precautions (EBP). The resident, who had multiple diagnoses including sepsis, dialysis dependency, diabetes, a left below-knee amputation, a right calf wound, and a pressure ulcer on the left buttock, required specific precautions to prevent infection transmission. Despite the signage on the resident's door indicating the need for gloves and gowns during high-contact care activities, the staff did not adhere to these requirements. During a transfer and toileting activity, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) involved only sanitized their hands and donned gloves, neglecting to wear gowns as mandated by the facility's policy. Additionally, the staff failed to sanitize the Hoyer lift after using it with the resident on EBP, which is a breach of the facility's policy on cleaning and disinfecting durable medical equipment. The lift was placed in the hallway without being sanitized, and a Certified Nursing Assistant (CNA) was observed attempting to use the contaminated lift on another resident. This oversight was only corrected after the surveyor intervened. The Nursing Home Administrator confirmed that the expectation was for the lift to be sanitized between residents and for staff to wear appropriate PPE, including gowns, during high-contact care activities for residents on EBP.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tomah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Hills Rehab Ctr | 14.8 mi | ★★★★★ | 8 | 0 |
| Morrow Memorial Home | 14.9 mi | ★★★★★ | 0 | 0 |
| Crest View Nursing Home | 18.3 mi | ★★★★★ | 3 | 0 |
| Elroy Health Services | 19.2 mi | ★★★★★ | 15 | 1 |
| Fair View Nursing And Rehabilitation Center | 25.4 mi | ★★★★★ | 10 | 0 |
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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.