Barron Care and Rehabilitation

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of every nurse aide at least every 12 months and provide 12 hours of regular in-service education based on the outcome of for 6 of 6 CNAs reviewed. This has the potential to affect all 47 residents. This is evidenced by:On 01/06/26, a sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information:CNA D has a hire date of 06/10/24. The annual performance review is dated 06/19/25. No documentation of in-service education based on performance review is noted. CNA K has a hire date of 04/24/24. The annual performance review is dated 08/12/25. No documentation of in-service education based on performance review is noted. CNA L has a hire date of 10/22/21. The annual performance review is dated 11/06/25. [...]

Inspectors wroteBased on interview and record review, the facility did not complete the required annual 12 hours of in-service training for nurse aides for 6 of 6 CNAs reviewed. This has the potential to affect all 47 residents. This is evidenced by:On 01/06/26, a sample of CNAs employed by the facility was selected for review for 12 hours of in-service training. The facility provided the following documentation:CNA D has a hire date of 06/10/24. No documentation of required annual 12 hours of in-service training. CNA K has a hire date of 04/24/24. No documentation of required annual 12 hours of in-service training. CNA L has a hire date of 10/22/21. No documentation of required annual 12 hours of in-service training. CNA M has a hire date of 04/15/24. No documentation of required annual 12 hours of in-service training. CNA N has a hire date of 04/12/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 4 of 4 residents reviewed for falls (R5, R7, R10, and R26), received adequate supervision and assistance to prevent accidents.

Inspectors wroteBased on observation, interview and record review, the facility did not provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections.-The facility did not ensure proper hand hygiene during water pass for 4 of 4 residents observed (R35, R18, R46, & R16).-The facility did not ensure appropriate personal protective equipment (PPE) was donned during wound care for 1 of 1 resident observed (R34).-The facility did not ensure appropriate PPE was donned while administering eye drops to 1 of 1 resident observed (R21).

Inspectors wroteBased on record review and interview, the facility must ensure each resident is free from unnecessary drugs as evidenced by completing adequate drug monitoring for 2 of 5 residents (R5 and R7) reviewed for unnecessary medication reviews.-The facility is not accurately monitoring resident-specific targeted behaviors for R7's psychotropic medication use. -The facility is not accurately monitoring resident-specific targeted behaviors for R5's psychotropic medication use. The facility policy titled, Psychotropic Medication, read in part, 4. Nursing will document daily on behaviors treated by antipsychotics/antianxiety/hypnotic. 8. PRN psychotropics and anti-anxiety medications will have behaviors to watch for and interventions to use prior to administration of medication. All behaviors and interventions used are to be documented. Example 1 R7 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 4 sampled residents reviewed.-The facility staff did not immediately respond to R7's wanderguard alarm, and R7 eloped from the facility.-The facility did not report R7's elopement within two hours, as the allegation involved potential neglect.-The facility did not submit the misconduct incident report within five business days of discovery of the incident. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation of an injury for unknown origin for 1 of 1 resident (R)(R26) reviewed. On 12/06/25, R26 was noted to have an injury of unknown origin. Facility did not complete education for all staff on all potential causations of injury. This is evidenced by:R26 was admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia severe with anxiety, Alzheimer's disease, fibromyalgia, weakness, contracture of muscle right thigh, contracture of muscle left thigh, contracture of muscle left lower leg, and contracture of muscle right lower leg. R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/21/25 noted a Brief Interview of Mental Status (BIMS) score not completed due to resident rarely/never understood. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan contained the minimum information to meet resident's immediate needs for 2 of 2 residents reviewed (R51 and R6).-Baseline care plan did not include weightbearing status related to broken humerus (R51)-Baseline care plan did not include immobilizer instructions/care (R51)-Baseline care plan did not include skin monitoring related to immobilizer (R51)-Baseline care plan did not include pain monitoring and interventions (R6)

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 13 resident care plans reviewed (R10).-R10's care plan was not revised after a fall. The facility policy titled, Care Plan Revision Upon Status Change, read in part, 1. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. D. The care plan will be updated with new or modified interventions. R10 was admitted to the facility on [DATE], diagnoses included Alzheimer's disease and history of falls. R10's Minimum Data Set (MDS) assessment completed on 05/02/25, confirmed R10 scored 06/10 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 2 residents reviewed (R7), received the necessary services to carry out Activities of Daily Living (ADLs). -The facility identified R7 had a decline in transfer status and did not follow up with the recommended therapy evaluation. R7's Minimum Data Set (MDS) assessment, completed on 12/08/25, confirmed R7 scored 04/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R7's MDS assessment revealed R7 requires assistance with all transfers. R7's care plan included:-Resident has ADL Self Care deficit r/t alteration in functional abilities, altered cognition, dementia with behaviors, low back pain. Date Initiated: 08/27/2025 Revision on: 12/12/2025.-Resident will improve in ADL function. Date Initiated: 08/27/2025 Revision on: 12/11/2025.-Transfer: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice that would meet each resident's physical, mental, and psychosocial needs.-The facility did not obtain and enter orders for 1 of 1 resident reviewed (R51).-The facility did not update provider related to new skin impairment for 1 of 1 resident reviewed (R10).-The facility did not implement interventions to assess skin under immobilizer to prevent skin breakdown for 1 of 1 resident reviewed (R26).

Inspectors wroteBased on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for one of one resident (R) reviewed for pressure injuries (R34). The facility did not provide, document, or evaluate interventions to prevent the development of multiple pressure injuries and/or promote healing of R34's pressure injuries. Facility did not have orders or documentation to perform daily skin assessments to assess R34's skin of R34's left foot, which had a post-operative shoe due to amputaion of left great toe. The facility's lack of skin assessments of R34's left foot lead to development of a stage 2 pressure injury on toip of R34's left foot because facility did not observe that there was no cushion between the skin on R34's left foot and the post-operative shoe. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with intermittent catheterization received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 1 of 1 resident (R)(R4) reviewed. R4 completed self-catheterization without facility assessment and indication of need. R4 developed a UTI on 12/02/25 and 12/31/25. This is evidenced by:Facility policy titled, Catheterization of a Male, with a date of 2025, states in part: Policy: Urinary catheterization will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. [...]

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure pain management interventions were provided for 1 out of 2 residents (R) reviewed for pain management. The facility did not assess and provide non-pharmacologic interventions to R6 as ordered for pain management. This is evidenced by:The facility policy titled, Pain Assessment & Scale dated 4/12/2001, reads in part. 3. Consider alternative pain relief measures such as: distraction, massage, cold or warm packs, repositioning, or backrub. R6 was admitted to the facility on [DATE]. Diagnoses include fracture of upper end of left humerus. R6's Minimum Data Set (MDS) assessment completed on 12/4/25 indicated R6 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. [...]

Inspectors wroteBased on observations, interview and record review, the facility did not ensure that a resident (R) who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 sampled resident (R3) reviewed for dialysis. The facility failed to provide ongoing assessment of R3's condition and monitoring for complications before and after dialysis treatments.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of less than 5% for 2 of 3 residents observed (R21, R22).-Facility had a medication error rate of 11.54%.-R21 received the wrong dose for two medications (artificial tears and Citalopram).-R22 received the wrong medication. R22 received Calcium with Vitamin D 500mg tab and the physician order was for Calcium Carbonate 1250 (500 Ca) and to give 2 tablets by mouth one time a day.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for two of three residents (R) reviewed for pressure injuries (R29 and R18.) R29 was admitted to the facility with no skin impairments and developed a stage 3 pressure injury to the coccyx area (tailbone) which remains unhealed, due to lack of comprehensive assessments, lack of timely care plan interventions, and lack of repositioning. This example is being cited at actual harm. Facility did not complete comprehensive assessment on admission of R18's present PIs and did not implement care plan interventions timely or follow the repositioning schedule to prevent a stage 2 pressure injury from occurring.

Inspectors wroteBased on interview and record review, the facility did not notify the resident/representative in writing of the reason for the transfer/discharge for 5 of 6 residents reviewed who were discharged (R10, R14, R25, R8, R15). This is evidenced by: The facility's policy titled Resident [NAME] of Rights documented, in part: 14. Transfer and Discharge .Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons, proposed date and location of transfer; record the reasons in the resident's clinical records; and include in the notice . Example 1 R10 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that written bed hold notice required for facility-initiated transfers was given to the residents or resident representatives for 5 of 6 residents reviewed for hospitalization (R10, R14, R25, R8, R15) This is evidence by: The facility's policy titled Bed Hold & Return to Facility with revised date of 05/03/24 documented, in part: It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Example 1 R10 was admitted to the facility on [DATE]. R10's medical record documented diagnoses in part, dementia with behavioral disturbance, Alzheimer's, Parkinson's, UTI, sepsis, infectious gastroenteritis, dysphagia, and CVA. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R13, R18, and R17) This is evidenced by: Example 1 Facility's policy titled Resident [NAME] of Rights documented in part: Quality of Life, 19. Dignity, The facility must promote and care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. R13's medical record documented current diagnoses including in part, Alzheimer's disease, major depressive disorder, dysphagia following cerebrovascular disease, CKD stage 3A, dementia, and mild protein-calorie malnutrition. [...]

Inspectors wroteBased on record review, observations and staff interview, the facility did not ensure 1 resident (R) (R18) of 15 sampled residents was reasonably accommodated with access to a call light. R18 was observed in R18's room without access to a call light or means to notify staff if assistance was needed.

Inspectors wroteBased on observation, interview and record review, the facility did not develop and initiate a comprehensive care plan with targeted interventions for a resident to maintain baseline Activities of Daily living (ADL)s. This occurred for 2 of 15 residents (R) reviewed for care planning, (R17 and R14)

Inspectors wroteBased on record review and interview, the facility did not review and revise comprehensive care plans for falls, incontinence, and activities of daily living for 2 of 15 residents (R)14 and R17). This is evidenced by: Example 1 R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. The MDS documented R14 had impairment to one side of the lower extremities. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 10 residents (R14) who are unable to carry out activities of daily living receive the necessary services for toileting and to maintain good personal hygiene. This is evidenced by: R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. R14 had inattention and disorganized thinking. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents with limited range of motion receive appropriate treatment and services to maintain or increase range of motion. This occurred for 1 of 2 residents (R) R17, who were reviewed for range of motion services. R8 has a left arm and left leg weakness following a stroke effecting non-dominant side. The resident's range of motion program was never started. This is evidenced by: R17 was admitted to the facility on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, atherosclerotic heart disease, essential hypertension, and osteoarthritis of left knee. R17's Minimum Data Set (MDS) assessment, dated 02/02/24, identified that R17 had a Brief Interview for Mental Status (BIMS) score of 12. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles for 1 of 2 insulin pen medications reviewed during medication administration observation. This had the potential for harm to affect resident (R)2. This is evidenced by: Current Wisconsin State pharmacy labeling requirements effective December 2020 state all prescription medications must include in part: .patient name, date of birth , name and strength of medication, dosage, route . R2 was admitted to facility on 04/30/20 with a pertinent diagnosis of diabetes mellitus II. R2 has a prescription order for Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 140 - 179 = 4; 180 - 219 = 6; 220 - 259 = 8; 260 - 299 = 10; 300 - 339 = 12; [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene with glove changes during morning cares and catheter cares for 2 of 4 residents (R). (R2 and for R29)

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 34 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied to prevent Legionella growth. - Include a process to confirm the WMP was being implemented and was effective. [...]

Inspectors wroteBased on observation and interview, the facility did not prepare, store or distribute food under sanitary conditions. This can potentially affect 11 of 33 residents (R) (R19, R29, R5, R9, R12, R26, R18, R28, R3, R16, R6) who ate all meals in their rooms. Staff were distributing food and drinks to rooms without covering them, potentially exposing residents to contaminated food.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive resident-centered care plan for 3 of 12 sampled residents (R28, R19 and R136). The facility did not develop a care plan for precautions or monitoring related to use of anticoagulation medication, or for immobility related to an amputation for R28. The facility did not develop a comprehensive resident-centered care plan for R19 who has a foley catheter. The facility did not develop a care plan for R136 who was on an antipsychotic medication. Evidenced by: The facility policy titled, Care Plan Process revised 04/30//2020, states in part, It is the policy of Care and Rehab- Barron to develop an initial baseline care plan addressing the major area of risk with 48 hours of admission. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not review and revise the comprehensive care plans for 1 of 12 sampled residents (R), R8. R8's care plan was not updated to identify the resident was experiencing severe weight loss. This is evidenced by: The facility policy, entitled Care Plan Process, dated May 5, 2010, stated: With every new MD order that changes the way a resident receives care or an incident that needs different interventions, or/and the onset of illness a temporary care plan will be put into place or the nurse must revise the care plan . If the problem will be longer than 21 days, add the problem to the main care plan in the chart and on the care plan in the resident room for the nurse aid. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure that residents who are fed by enteral means received the appropriate treatment to prevent complications of enteral feeding in 2 of 2 residents (R32, R136) observed for cares with a gastric tube (g-tube). Surveyors observed enteral feedings to R32 and R136 and confirmation of placement was not checked prior to the administration.

Inspectors wroteBased on interview and record review, the facility did not ensure that psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed or specific behaviors in the clinical record. The facility did not implement targeted behavioral monitoring, assessment or implement alternate interventions, prior to initiating or increasing the dosage and frequency of a psychotropic medication for 1 of 8 residents (R) 29. This is evidenced by: The facility policy entitled Behavior Observation and Monitoring revised 11/17/16, states: Resident's identified with targeted behavior will be monitored on a daily basis, will be recording identifying target behaviors, interventions, outcomes of interventions, and frequency of behaviors exhibited. R29 was admitted to the facility on [DATE] and has a diagnosis of Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents were free from medication errors for 2 of 2 sampled residents (R32 and R136) getting medications through a G-tube.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident (R) is offered a pneumococcal immunization for 1 resident (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation of R29 being screened and offered pneumococcal vaccine.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident (R) is offered a Covid-19 Immunization for 1 resident (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation of R29 being screened and offered Covid-19 Immunization. The facility policy, entitled: Covid 19, revised 09/26/23, states: .all residents will be offered Covid 19 vaccine. Vaccinations will be required per CMS guidelines. R29 was admitted to the facility on [DATE] and has a diagnosis of Alzheimer's disease, chronic bronchitis (an inflammation of the airways that carry air to your lungs), immunodeficiency due to conditions classified elsewhere (deficiency of immune response or a disorder characterized by deficient immune response). [...]