Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wisconsin Rapids Health Services during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions and improper food storage in a second-floor kitchenette used for resident meal service. Mouse droppings were observed in multiple cabinets under and beside the sink, along with several mouse traps, despite prior pest control visits documenting droppings in the same area. The Maintenance Director and Housekeeping Supervisor acknowledged an ongoing mouse problem, and the Dietary Manager confirmed there was no documented schedule for cleaning cabinet interiors as required by facility policy. In the same kitchenette refrigerator, surveyors found multiple resident and family food items that were unlabeled, undated, and/or past their best-by or use-by dates, including condiments, beverages, sandwiches, and cream pie, contrary to the facility’s policy requiring labeling and timely disposal of prepared foods.
A resident with moderate cognitive impairment was allegedly yelled at by a CNA after triggering an alarm, as reported by the resident's spouse. The incident was documented and internally investigated, but the facility did not report the allegation of verbal abuse to the State Agency as required by policy.
A resident with moderate cognitive impairment was allegedly yelled at by a CNA after an alarm was triggered, as reported by the resident's spouse. The facility did not conduct a thorough investigation into the verbal abuse allegation, failing to interview involved parties or provide follow-up, contrary to its abuse policy.
Two residents did not receive safe and accurate medication administration when a nurse failed to properly administer and document Ozempic injections, including compensating for a leaking dose without proper documentation, and another nurse recorded a dose as given when it was not administered. Additionally, a nurse did not follow correct technique when administering insulin with a pen, removing it too quickly from a resident's skin.
A resident with significant mobility limitations was unable to transfer out of bed for several days due to a bariatric Hoyer lift being out of service. Staff had been sharing remotes between two bariatric lifts for weeks because of a malfunction, and maintenance checks were not consistently documented. There was confusion among staff about which lifts were operational, and the lack of timely reporting and resolution of equipment issues led to the deficiency.
A resident with multiple complex medical conditions experienced repeated meal refusals and poor oral intake over several days, but the facility did not notify the physician as required by policy. Staff and nurse practitioners confirmed that notification should have occurred after multiple consecutive meal refusals. The physician was only notified after the resident showed acute signs of decline and dehydration, resulting in hospitalization.
Staff failed to follow infection prevention protocols during care for two residents, including not performing hand hygiene between glove changes, touching multiple surfaces with soiled gloves, and not wearing required PPE such as gowns during high-contact activities for a resident on enhanced barrier precautions for MRSA. Hand sanitizer was not accessible in resident rooms, and staff expressed confusion about which infection control signage to follow.
A resident with moderate cognitive impairment and an activated POAHC received a COVID-19 vaccine without a signed consent form in the medical record, as required by facility policy. Staff obtained verbal authorization from the POAHC and later from the resident, but failed to secure and document the necessary signed consent prior to vaccine administration.
A facility failed to investigate and resolve a grievance regarding medication administration for a resident during a respite stay. Despite the facility's policy, the grievance was not addressed, and no resolution was provided. The resident's medical record indicated medications were administered, but inconsistencies were found in staff interviews and documentation. The facility did not follow its grievance process, leading to the deficiency.
Two residents in an LTC facility experienced inadequate pressure ulcer care, leading to the development and worsening of pressure injuries. One resident, admitted with a sacral pressure injury, developed multiple unstageable pressure injuries due to delayed care planning and intervention. Another resident with stage IV pressure injuries did not receive consistent care, missed wound clinic appointments, and was not repositioned as required. The facility's failures in care planning, intervention, and communication resulted in actual harm to the residents.
The facility failed to maintain a clean and sanitary environment for food preparation, affecting over 75% of residents. Missing documentation in sanitization logs and refrigerator temperatures was noted, indicating non-compliance with FDA guidelines. This included missing records of sanitizing solution concentration and cold storage temperatures over several months.
The facility failed to notify the State Long Term Care Ombudsman about hospital transfers for four residents, despite multiple hospitalizations for various medical conditions. Documentation of these notifications was absent, and the facility's communication only included admissions, discharges, and deaths, omitting the required hospital transfer notices.
A long-term care facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE and hand hygiene protocols. Staff were observed providing care to residents on enhanced barrier and contact precautions without proper PPE, and hand hygiene practices were inadequate during personal and wound care. These deficiencies increased the risk of infection transmission among residents.
A resident with cardiomyopathy ischemic, hypertension, and congestive heart failure was admitted to Hospice services, but the facility failed to complete a Significant Change in Status MDS assessment within the required timeframe. The DON confirmed the oversight, and the facility lacked a policy on Significant Change MDS assessments.
A resident with multiple medical conditions was admitted and later discharged without a baseline care plan being developed and implemented within 48 hours, as required. The DON confirmed the oversight during an interview but could not provide the necessary documentation.
Two residents in an LTC facility were found to have incomplete care plans. One resident, prescribed trazodone for insomnia, lacked a sleep hygiene care plan with non-pharmacological interventions. Another resident with venous insufficiency had no comprehensive care plan for skin integrity, as the previous plan was resolved and not replaced. These deficiencies were confirmed by the DON during a survey.
A resident discharged from the facility did not receive a discharge summary with a recapitulation of stay. The resident, admitted with multiple diagnoses including orthopedic aftercare and diabetes, left the facility before completing skilled services. The surveyor found no recapitulation in the medical record, and the DON confirmed it was not completed as expected.
A resident receiving enteral feeding had their feeding tube placement inadequately verified, leading to a deficiency. The resident, with dysphagia and esophageal obstruction, required gastrostomy tube feeding. A nurse administered a flush without checking the tube's placement as per facility policy, relying instead on listening for a 'whoosh' sound. This action was contrary to the protocol of verifying external markings and tube length, as observed by a surveyor.
A facility failed to follow proper procedures for insulin administration, as a nurse used an insulin syringe to draw insulin from a pre-filled pen, contrary to guidelines. A resident expressed concerns about blood sugar control, and the DON and pharmacist were unaware of this practice, which was not supported by facility policy or external guidelines.
A facility failed to comprehensively assess a resident prescribed trazodone for insomnia, lacking a sleep hygiene care plan and non-pharmacological interventions. No sleep behavior monitoring was documented to evaluate the medication's effectiveness. The DON confirmed the last sleep assessment was incomplete, and routine checks did not document the resident's sleep status, leading to the deficiency.
The facility did not ensure residents were treated with dignity during meals, as observed with two residents. A CNA stood while feeding a resident with Alzheimer's and another with Parkinson's, contrary to their care plans. The DON confirmed staff should be seated when assisting with meals, highlighting a breach in the facility's dining policy.
The facility failed to maintain sanitary food storage and proper labeling practices. Various undated, unlabeled, or expired food items were found in the kitchenettes, and two thawed, undated shakes were observed on a medication cart. Staff acknowledged the disorganization and lack of cleanliness, with dietary aides responsible for dating and cleaning. This posed a potential risk to residents' safety.
The facility failed to provide timely assistance with ADLs for three residents. One resident did not receive scheduled showers, another did not receive consistent diabetic nail care, and a third experienced a 26-minute delay in call light response. The facility's policies were not adequately followed, leading to these deficiencies.
The facility failed to provide adequate care for two residents with pressure injuries. One resident did not receive proper hand hygiene during wound care, and pressure-relieving measures were not consistently implemented, leading to the deterioration of existing wounds. Another resident's care plan to float heels and use heel lift boots was not consistently followed, as the resident's heels were in direct contact with the mattress. The facility's lapses in protocol and documentation contributed to these deficiencies.
Two residents in the facility did not receive appropriate respiratory care. One resident was given CPAP therapy without a physician's order and lacked the necessary BiPAP equipment, while another resident had a CPAP order but no corresponding care plan. Interviews confirmed these deficiencies in respiratory care management.
A resident received incorrect medication due to a transcription error, leading to the administration of triple antibiotic ointment instead of the prescribed triamcinolone ointment. The resident also missed several doses of the correct medication and experienced a reaction to it, which was not properly documented or communicated.
Unsanitary Kitchenette Conditions and Improper Food Storage
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner and that the kitchenette and related food service areas were maintained in a clean condition, affecting residents on the second floor who used that dining area. Surveyors observed mouse droppings in two cabinets in the kitchenette adjacent to the second-floor dining room, including under the sink and in a cabinet to the left of the sink, along with several mouse traps on the floor and inside the cabinet. Pest control records showed prior findings of mouse droppings in the same kitchenette area and the placement of bait stations, as well as a note advising cleanup of mouse droppings. The Maintenance Director and Housekeeping Supervisor acknowledged there had been a mouse problem and that several mice had been caught. The Dietary Manager confirmed there was no cleaning schedule documenting when the interior of the cabinets was last cleaned and was unsure whether the droppings were new or old, despite facility policy requiring cleanliness and sanitation of dining and food service areas through a written, comprehensive cleaning schedule. The facility also failed to ensure that food stored in the kitchenette refrigerator was properly labeled, dated, and discarded in accordance with policy, which required prepared food brought in by families or visitors to be labeled with content and date, consumed within three days, or disposed of by staff. During inspection of the refrigerator, surveyors found multiple items that were unlabeled, undated, and/or past their best-by or use-by dates, including resident-labeled apple butter, salad dressings, jam, pickles, apple cider, an undated meat and lettuce sandwich, another unlabeled sandwich, and undated cream pie pieces labeled with a resident’s name. The Dietary Manager stated that residents and families use the refrigerator and kitchen items and that it was everyone’s responsibility to ensure items were labeled, dated, and expired items discarded, and confirmed that the observed expired and unlabeled items should have been labeled and/or disposed of.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Agency as required by its Abuse, Neglect, and Exploitation policy. On 9/3/25, a resident (R8) reported that a Certified Nursing Assistant (CNA-E) yelled at another resident (R7), who was R8's spouse, after an alarm was triggered when R7 attempted to get a remote while in a wheelchair. The incident was documented as a grievance, and the Nursing Home Administrator (NHA-A) conducted an internal investigation. However, there was no follow-up or confirmation of the incident, and the facility did not report the allegation to the State Agency within the required timeframe. R7, the resident involved, had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed to have moderate cognitive impairment. R8, the reporting resident, was not cognitively impaired. Despite the facility's policy requiring all alleged violations to be reported to the Administrator and State Agency within specified timeframes, the NHA-A did not report the incident, citing personal knowledge of the individuals involved and a belief that the CNA's tone was misinterpreted. The deficiency was confirmed during a surveyor interview with the NHA-A.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with moderate cognitive impairment. According to the report, a grievance was filed by another resident, who is the spouse of the alleged victim, stating that a CNA yelled at the resident after an alarm was triggered when the resident attempted to get a remote while in a wheelchair. The facility's policy requires immediate and thorough investigation of any abuse allegations, including interviews and documentation. However, the investigation was not comprehensive; staff did not confirm or deny the incident, and there was no follow-up or further information documented. The Nursing Home Administrator acknowledged that a thorough investigation was not completed and attributed the incident to a possible misinterpretation of the CNA's tone. The administrator also confirmed that no resident or staff interviews were conducted as part of the investigation, and there was no staff education provided regarding the incident. The lack of a complete investigation did not align with the facility's abuse policy, which mandates prompt and thorough response to all allegations of abuse.
Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
Two residents experienced deficiencies in the administration of medications as prescribed. One resident, with diagnoses including type 2 diabetes, morbid obesity, and chronic kidney disease, had an order for Ozempic to be administered subcutaneously once weekly. On one occasion, a registered nurse observed medication leaking from the injection site and attempted to compensate by administering an additional amount, but did not document the altered dose or notify the provider or facility administration. On a subsequent occasion, another nurse did not have the medication available to administer, yet the medication administration record incorrectly indicated that the dose had been given. The nurse verbally communicated the missed dose, but the documentation did not reflect the actual event, leading to inaccurate records regarding medication administration. Another resident, with diagnoses including diabetes and severely impaired cognition, had an order for sliding scale Lispro insulin to be administered subcutaneously three times daily. During an observed medication pass, a registered nurse administered the insulin using an injectable pen but did not hold the pen to the resident's skin for the recommended duration, removing it in less than two seconds instead of the required five to ten seconds. This action was inconsistent with the facility's policy and the manufacturer's instructions for proper insulin pen use. These events were identified through observation, staff interviews, and record review, revealing failures to follow established medication administration protocols, accurately document medication administration, and ensure that medications were administered as ordered for both residents.
Failure to Maintain Safe and Available Mechanical Lifts for Resident Transfers
Penalty
Summary
The facility failed to ensure that essential mechanical lifts were maintained in safe operating condition, directly affecting a resident who required a bariatric Hoyer lift for transfers. The resident, who had multiple diagnoses including morbid obesity, chronic respiratory failure, and limited mobility, was unable to transfer out of bed for a four-day period when the bariatric Hoyer lift was out of service. Staff interviews and record reviews confirmed that the resident required assistance from two staff members and a Hoyer lift with a specific sling for transfers to an electric wheelchair, as documented in the care plan. Prior to the lift becoming completely inoperable, staff had been sharing hand remotes between the bariatric Hoyer lift and a bariatric EZ stand lift for approximately two weeks because one of the remotes was not working. Maintenance staff were aware of the issue and had ordered a new remote, but there was a delay in receiving it. During this period, the facility's policy requiring mechanical lifts to be available and accessible 24 hours per day was not met, and routine checks and maintenance were not consistently documented, especially for rented equipment. Multiple staff members, including CNAs and LPNs, confirmed the lifts were not functioning and that there was confusion regarding which lifts were operational. The maintenance director acknowledged that inspections of rented lifts were not documented, and the nursing home administrator was not fully aware of the impact on the resident. Additionally, there was no staff education on timely reporting of equipment issues, contributing to the delay in resolving the deficiency.
Failure to Notify Physician of Change in Condition Due to Meal Refusals
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a significant change in condition for a resident with multiple complex medical diagnoses, including paraplegia, protein-calorie malnutrition, and several pressure ulcers. The resident had a care plan identifying risk for nutritional status change and poor oral intake, with interventions to encourage and assist with food and fluid consumption. Despite this, the resident refused at least two meals per day on multiple days in March, with documentation showing several instances of consecutive meal refusals and poor intake, but there was no evidence that the physician was notified of these refusals as required by facility policy and the INTERACT Change in Condition tool. The resident's medical record indicated ongoing poor nutritional intake, with an average of 0-25% of meals consumed and multiple days where two or more meals were refused. On specific dates, the resident refused all meals or had five consecutive meal refusals, and fluid intake was also low or refused on some occasions. Staff interviews confirmed that the resident regularly refused meals, and both nurse practitioners interviewed stated they would have wanted to be notified if a resident refused five meals in a row. However, there was no documentation that such notification occurred prior to the resident's acute decline. The deficiency was further evidenced when the resident experienced a significant change in condition, including signs of dehydration, poor skin turgor, sunken eyes, and decreased responsiveness, which ultimately led to hospitalization. Only at this acute stage was the physician notified and action taken. The lack of timely physician notification regarding the resident's ongoing meal refusals and poor intake, as required by policy, contributed to a delay in medical assessment and intervention.
Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the provision of care for two residents. In one instance, a certified nursing assistant (CNA) provided morning care to a resident with a seizure disorder and malnutrition who had urinated and had a bowel movement in bed. The CNA donned gloves but did not have wipes or a garbage can nearby, touched multiple surfaces with soiled gloves, and changed gloves four times without performing hand hygiene between changes. Hand sanitizer was not readily available in the resident's room, and the CNA acknowledged not performing hand hygiene during glove changes or after touching contaminated items. In another case, a resident with diabetes, MRSA, and cellulitis, who was on enhanced barrier precautions (EBP) due to venous wounds and a MRSA infection, was transferred from bed to toilet by a CNA and an LPN. Both staff members donned gloves but did not wear gowns as required by the EBP and contact precautions signage posted on the resident's door. The staff were observed transferring the resident without the appropriate PPE, and both later confirmed they did not follow the signage instructions, with the LPN expressing confusion about which sign to follow. The Director of Nursing (DON) confirmed that staff should perform hand hygiene when moving from dirty to clean tasks and when donning new gloves, and that gowns should have been worn during the transfer for a resident on EBP and contact precautions. The DON also acknowledged that hand sanitizer was not accessible in resident rooms and that infection control audits were primarily conducted on other shifts, not during the night shift when the deficiencies were observed.
Lack of Signed COVID-19 Vaccine Consent for Resident with POAHC
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a signed COVID-19 vaccination consent was present in the medical record for a resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC). The facility's policy required a signed consent prior to vaccine administration, but only verbal consent was obtained and documented for the COVID-19 vaccine. The registered nurse (RN) contacted the resident's POAHC by phone and received verbal authorization, then mailed a consent form for signature, which was not returned. The RN did not document the verbal conversation in the resident's medical record, and the POAHC later stated that authorization for all vaccines except COVID-19 was given, with the resident themselves authorizing the COVID-19 vaccine at a later date, despite the POAHC being activated for medical decisions. The Director of Nursing (DON) confirmed that the facility typically works off verbal consents and was unaware of the specific communication between the POAHC and the former DON. The resident's medical record contained a consent form indicating verbal consent, but lacked the required signed authorization as per facility policy. The deficiency was identified through interviews with staff and the POAHC, as well as review of the resident's medical record and facility policy.
Failure to Investigate and Resolve Medication Grievance
Penalty
Summary
The facility failed to promptly investigate and resolve a grievance regarding medication administration for a resident during a respite stay. The grievance, which was emailed to the facility, indicated that certain medications were not administered to the resident. Despite the facility's grievance policy requiring timely resolution, the grievance was not investigated, and no resolution was provided. The resident, who was admitted for a Hospice respite stay, had multiple diagnoses including congestive heart failure and end-stage renal disease. The medical record indicated that medications such as levothyroxine and furosemide were administered as ordered, but the medication administration record did not show any doses were refused or not administered. Interviews with nursing staff revealed inconsistencies in the medication administration process, with some staff recalling the use of pharmacy-supplied medications and others mentioning the possibility of using medications brought from home. The Director of Nursing and Social Worker were unable to provide documentation or evidence of the medications being at the facility or being administered. The Hospice provider's records indicated that the resident's family was concerned about medications not being administered, as the medications sent with the resident returned home unused. The facility did not follow its grievance process, and a thorough investigation was not completed, leading to the deficiency.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R151 and R32, leading to the development and worsening of pressure injuries. R151 was admitted with a sacral pressure injury and was assessed to be at risk for further pressure injuries. Despite this, the facility did not develop a care plan or implement necessary interventions to off-load pressure from R151's lower extremities and sacral wound until several days after admission. This delay resulted in the development of multiple unstageable pressure injuries. Observations revealed that R151's feet were not properly off-loaded, and heel protectors were not used as ordered, contributing to the deterioration of R151's condition. R32, who had existing stage IV pressure injuries, did not receive consistent care as per the care plan. The facility failed to complete weekly pressure injury assessments and missed multiple wound clinic appointments. R32's care plan required repositioning every hour, but observations indicated that R32 was left sitting in a wheelchair for extended periods without repositioning. Additionally, the facility did not apply the wound vac as ordered, and there were inconsistencies in wound measurements between the facility and the wound clinic, indicating a lack of proper assessment and documentation. The deficiencies in care for both residents were compounded by inadequate communication and documentation. The facility did not notify the wound clinic of changes in R32's wound care, such as the removal of the wound vac, and there was a lack of documentation regarding R151's refusal of care. These failures in care planning, intervention implementation, and communication led to actual harm for the residents, as evidenced by the worsening of their pressure injuries.
Removal Plan
- Completed wound assessments for residents with pressure injuries and skin assessments for all in-house residents.
- Updated care plans with pressure prevention interventions.
- Educated licensed nursing staff on the facility's policy, assessing residents upon admission, implementing pressure injury prevention interventions, implementing treatment orders, documentation, and provider notification.
- Educated nursing and therapy staff on implementing pressure injury prevention interventions.
- Implemented audits to ensure compliance.
Deficiency in Food Safety and Sanitation Documentation
Penalty
Summary
The facility failed to ensure that food was prepared in a clean and sanitary environment, which had the potential to affect over 75% of the 48 residents, as two of the residents received tube feeding. The deficiency was identified during an initial tour with the Dietary Manager, where the surveyor noted missing documentation in the sanitization logs. Specifically, the logs lacked records of parts per million (PPM) for the sanitization solution and sink wash temperatures on multiple dates in August, September, and October 2024. This lack of documentation indicates that staff did not consistently test or record the concentration of the sanitizing solution, as required by the 2022 FDA Food Code. Additionally, the facility did not consistently document refrigerator and freezer temperatures, which is crucial for maintaining food safety. During the same tour, the surveyor observed missing temperature records for cold storage on several dates in October, as well as in August and September 2024. The absence of these records suggests that the facility did not adhere to the FDA Food Code's guidelines for cooling and storing food at safe temperatures. These lapses in documentation and monitoring could compromise the safety and quality of food served to the residents.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman regarding the transfer or discharge of four residents to the hospital. This deficiency was identified through interviews and record reviews conducted by surveyors. The residents involved were hospitalized for various medical conditions, including changes in condition, complications from surgery, gastrointestinal bleeding, and unplanned discharges. Despite these hospitalizations, the facility did not have documentation of the required notices being sent to the Ombudsman. For instance, one resident was hospitalized multiple times for a change in condition, and the Director of Nursing confirmed the absence of notification documentation. Another resident, who had undergone surgery for colon cancer, was transferred to the hospital twice, yet the facility's email to the Ombudsman did not include these transfers. Similarly, a resident with a gastrointestinal bleed and another with unplanned discharges were transferred to the hospital without the Ombudsman being notified. The facility's communication to the Ombudsman only included admissions, discharges, and deaths, omitting hospital transfers.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper personal protective equipment (PPE) usage and inadequate hand hygiene practices. Staff members were observed providing care to residents on enhanced barrier precautions (EBP) and contact precautions without wearing the necessary gowns and gloves. For example, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) entered a resident's room without donning PPE, despite the resident being on contact precautions due to methicillin-susceptible Staphylococcus aureus (MSSA). Similarly, another resident with a gastrostomy tube was assisted with a Hoyer lift by staff who did not wear gowns, contrary to the facility's policy. In addition to PPE violations, the facility's staff demonstrated poor hand hygiene practices during personal care and wound care activities. For instance, two CNAs provided personal care to a resident without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. Another RN was observed performing wound care without wearing a gown and failed to turn off the faucet with a paper towel after washing hands, which is against the facility's hand hygiene policy. The facility's Director of Nursing (DON) acknowledged the lapses in infection control practices, indicating that staff were provided education and audited for compliance. However, the observed deficiencies suggest a lack of adherence to the facility's policies and the Centers for Disease Control and Prevention (CDC) guidelines. These failures in infection control practices had the potential to affect several residents, increasing the risk of transmission of communicable diseases and infections.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days after a significant change in condition was identified for a resident. The resident, who was admitted to the facility with diagnoses including cardiomyopathy ischemic, hypertension, and congestive heart failure, was admitted to Hospice services on June 24, 2024. Despite this significant change, the facility did not complete a Significant Change MDS assessment. The most recent MDS assessment on record was a Medicare - 5 day assessment. During an interview, the Director of Nursing confirmed with the MDS Coordinator that the assessment had not been completed. Additionally, the facility did not have a policy in place regarding Significant Change MDS assessments.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for one of the residents reviewed. The resident, who was admitted and later discharged, had multiple diagnoses including orthopedic aftercare, diabetes mellitus type 2, and several other medical conditions. Upon review of the resident's medical record, the surveyor was unable to find evidence of a baseline care plan. During an interview, the Director of Nursing acknowledged that a baseline care plan should have been completed within the required timeframe but was unable to locate the necessary documentation.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their medical and psychosocial needs. One resident, who was prescribed trazodone for insomnia, did not have a sleep hygiene care plan with interventions to promote sleep. Despite being cognitively intact and requiring assistance with activities of daily living, the resident's care plan lacked non-pharmacological interventions to support sleep, as confirmed by the Director of Nursing during an interview. Another resident, also cognitively intact, had a diagnosis of venous insufficiency and was under wound care management. However, the facility did not maintain a comprehensive care plan for skin integrity, as the existing care plan was resolved and removed without being replaced. This oversight was acknowledged by the Director of Nursing when the surveyor inquired about the missing care plan, highlighting a lapse in maintaining ongoing care documentation for the resident's condition.
Failure to Provide Discharge Summary with Recapitulation of Stay
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of stay for a resident who was discharged. The resident, identified as R49, was admitted to the facility with multiple diagnoses, including orthopedic aftercare, diabetes mellitus type 2, and emphysema, among others. R49 was admitted following a C3-C6 laminectomy and planned to discharge home. On the date of discharge, R49 chose to leave the facility before the completion of skilled services. Upon review, the surveyor found that R49's medical record did not contain a recapitulation of stay. During an interview, the Director of Nursing acknowledged the absence of the recapitulation and confirmed it should have been completed.
Failure to Verify Feeding Tube Placement
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding had their feeding tube placement verified according to established protocols, leading to a deficiency. Resident R40, who was admitted with dysphagia following a stroke and esophageal obstruction, required nutrition via a gastrostomy tube. The facility's policy required staff to verify the tube's placement by checking the external markings and gently tugging on the tube before administering feedings or flushes. However, during an observation, a registered nurse (RN) administered a flush without verifying the tube's placement as per the policy. Instead, the RN relied on listening for a 'whoosh' sound, which is not in line with the facility's procedures. The deficiency was identified during a survey when the surveyor observed the RN's actions and questioned the method used to verify the tube's placement. The RN admitted to not checking the tube's markings or measuring its length, which contradicted the facility's policy. The Director of Nursing acknowledged the oversight and indicated that the nursing staff should be aware of the correct procedures for checking feeding tube placement. This incident highlights a lapse in following the facility's established protocols for ensuring the safe administration of enteral feedings.
Improper Insulin Administration Practice
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of insulin to a resident, identified as R25. During an observation, a Registered Nurse (RN) was seen using an insulin syringe to draw insulin from a pre-filled insulin pen, which is not recommended according to the facility's policy or external guidelines. The facility's policy on medication administration did not specify whether using an insulin syringe to draw insulin from a pre-filled pen was appropriate. The Institute for Safe Medication Practices and the ASHP guidance document both advise against using insulin pen cartridges as vials due to risks of contamination and dosing errors. The resident, R25, expressed concerns about her blood sugar levels, noting they were more controlled when insulin was administered differently. The Director of Nursing (DON) was unaware of any order allowing this practice and confirmed that the facility's policy did not support drawing insulin from pens. The pharmacist was also unaware of this practice and assumed insulin was being provided in vials as per the order in the Medication Administration Record (MAR). The pharmacist stated that drawing insulin from a pen is not recommended due to the higher risk of error.
Deficiency in Psychotropic Medication Assessment and Monitoring
Penalty
Summary
The facility failed to ensure that a resident prescribed psychotropic medication was comprehensively assessed and had non-pharmacological interventions implemented to determine the adequate indication for the use of the medication. The resident, who was prescribed trazodone for insomnia, did not have a sleep hygiene care plan developed, nor were there any documented non-pharmacological interventions to promote sleep. Additionally, there was no documentation of sleep behavior monitoring over the last 30 days to assess the effectiveness of the medication. The Director of Nursing (DON) confirmed that the sleep assessment conducted in November of the previous year was incomplete, lacking a care plan and interventions. The facility did not conduct regular audits to determine the resident's sleep pattern or the continued need for trazodone. The only sleep study available was from 2019, and the staff's routine checks on the resident's ostomy bag did not include documentation of the resident's sleep status. This lack of comprehensive assessment and monitoring led to the deficiency identified by the surveyor.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during meal times, as observed in the cases of two residents. Resident 24, who has Alzheimer's disease and anemia, was observed being fed by a CNA who stood over her, contrary to the care plan that required assistance with setup and encouragement to eat. Similarly, Resident 16, diagnosed with Parkinson's disease and legal blindness, was fed by the same CNA while standing, despite the care plan indicating the resident was independent after setup and required assistance only as needed. The Director of Nursing acknowledged that staff should be seated when assisting residents with meals, indicating a deviation from the facility's policy on enhancing the dining experience through person-centered care.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that food was stored in a sanitary manner and appropriately labeled and dated, as observed during a survey. In the Cedar Ridge, Bear Creek, and Deer Trails kitchenettes, various food items were found undated, unlabeled, or expired. These included containers of fruit punch, protein drinks, lemonade, cranberry juice, milk, orange sherbet, dill dip, cranberry almond chicken salad, and rotten cucumbers. Additionally, a pitcher with a sediment ring was found, indicating unsanitary conditions. Dietary Aide (DA)-E acknowledged the disorganization and lack of cleanliness in the Deer Trails unit refrigerator and confirmed that kitchen staff were responsible for dating and cleaning items. Dietary Director (DD)-D confirmed that unit refrigerators could be used for resident food, which should be labeled, dated, and kept for no more than seven days. Furthermore, the surveyor observed two thawed and undated Sysco Imperial vanilla shakes on a medication cart in the Cedar Ridge unit. The instructions on the shakes indicated they should be stored frozen, thawed under refrigeration, and used within 14 days of thawing. LPN-J confirmed that the shakes were not dated when removed from the freezer. DD-D stated that supplements are typically dated 10 days from removal from the freezer and delivered to units by dietary staff, although sometimes nurses might remove them without dating. This lack of proper labeling and dating of food items and supplements posed a potential risk to residents' safety.
Deficiencies in ADL Assistance and Call Light Response
Penalty
Summary
The facility failed to provide necessary and timely assistance with activities of daily living (ADLs) for three residents. One resident, who was dependent on staff for bathing, did not receive showers as scheduled. The resident was supposed to receive a shower every Tuesday, but there were significant gaps between the showers provided, with intervals of 11 and 14 days without a shower. The Director of Nursing confirmed that the documentation indicated missed showers, which should have been provided weekly. Another resident, who had a medical condition requiring weekly diabetic nail care, did not receive consistent nail care. The resident's care plan did not include an intervention for nail care, and the facility failed to document nail care consistently. During an interview, a registered nurse was unable to confirm when the resident's nails were last cut, and the resident's nails were observed to be long and untrimmed. A third resident experienced a delay in response to their call light, which was activated for approximately 26 minutes before staff responded. The resident, who had been admitted the previous day, wanted to get out of bed but was left waiting due to staff being occupied with other duties. The facility's policy did not specify an appropriate call light response time, but the delay was acknowledged as excessive by the Regional Consultant.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and manage pressure injuries for two residents, R1 and R7. For R1, the facility did not ensure appropriate hand hygiene during wound care, and care-planned pressure-relieving measures were not consistently implemented. R1's medical record lacked proper wound assessment documentation and timely response to newly opened areas. R1 was admitted with a laceration, a blister, and red, spongy heels, and later developed multiple stage 3 and stage 4 pressure injuries, which were not present upon admission. The facility's failure to conduct thorough assessments and consult the wound MD sooner contributed to the deterioration of R1's wounds. During an observation, RN-F did not change gloves or perform hand hygiene between dressing changes and when moving from soiled to clean parts of the dressing change. RN-F also failed to perform hand hygiene immediately after removing gloves and PPE. Additionally, R1's heel lift boots were not in place as required by the care plan. The Director of Nursing and Assistant Director of Nursing acknowledged these lapses in protocol and documentation, which hindered the facility's ability to provide effective wound care and prevent further deterioration of R1's pressure injuries. For R7, the facility did not consistently implement the care plan intervention to float/elevate heels and use heel lift boots. R7 had a history of a pressure injury on the left heel, and the care plan included interventions to prevent further injury. However, during an observation, R7's heels were in direct contact with the mattress, and R7 was not wearing heel boots or poseys. R7 expressed discomfort with the boots, stating they scraped the skin, which led to non-compliance with the intervention. The facility's failure to address R7's concerns and ensure consistent implementation of pressure-relieving measures contributed to the deficiency in care.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, R3 and R5, as identified during a survey. R3 was admitted with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and obstructive sleep apnea. Despite having a physician's order for BiPAP therapy, R3 was provided with CPAP therapy without a physician's order, and the facility did not obtain the required BiPAP equipment. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that R3 received CPAP therapy without an order and that the care plan did not reflect the use of CPAP therapy. Additionally, the Respiratory Therapy Company had no record of the facility requesting BiPAP equipment for R3. R5, who was admitted with a diagnosis of obstructive sleep apnea, had a physician's order for CPAP therapy. However, R5's care plan did not address the need for or use of CPAP therapy. Interviews with the Assistant Director of Nursing and Nursing Home Administrator confirmed that a care plan should have been in place to address R5's CPAP therapy needs. The lack of a care plan for R5 and the inappropriate use of CPAP therapy for R3 without a physician's order highlight deficiencies in the facility's respiratory care management.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility did not ensure accurate administration of medication for one resident (R4) due to a transcription error. R4, who had intact cognition and was responsible for their healthcare decisions, received an incorrect medication (triple antibiotic ointment) instead of the prescribed triamcinolone ointment. This error occurred after R4 returned from a dermatology appointment with a handwritten order for triamcinolone ointment. The error was identified when R4's medical record and treatment administration record (TAR) were reviewed, revealing that R4 received the incorrect medication from 2/7/24 to 2/20/24 and missed several doses of the correct medication from 2/27/24 to 3/6/24. Additionally, R4 refused several doses of the triamcinolone ointment due to a reaction, which was not properly documented or communicated to the dermatology clinic in a timely manner. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the transcription error and the administration of the incorrect medication. The LPN indicated that they had difficulty contacting the dermatology clinic to discontinue the triamcinolone ointment after R4 had a reaction. The DON verified that the facility did not have an order to administer the triple antibiotic ointment and acknowledged the need for staff to clarify unclear orders rather than guessing. The facility also lacked documented staff education regarding medication and transcription errors following the incident.
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 12 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 Wisconsin Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of Wisconsin Rapids | 2.2 mi | ★★★★★ | 1 | 0 |
| Edgewater Haven Nursing Home | 2.8 mi | ★★★★★ | 10 | 0 |
| Stevens Point Health Services | 14 mi | ★★★★★ | 0 | 0 |
| Timber Ridge Health And Rehabilitation | 14.8 mi | ★★★★★ | 1 | 0 |
| North Shore Healthcare At Marshfield | 26.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.