Suring Health and Rehab Center

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication. This practice had the potential to affect more than 4 of the 40 residents residing in the facility. The facility's controlled substance record books were missing signatures for narcotic counts.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 6 residents (R) (R12, R13, R2, R7, R14, and R15) of 12 sampled residents. R12 had a gastric tube. An enhanced barrier precautions (EBP) sign was not posted outside the entrance to R12's room. R12's care plan stated R12 was on universal precautions. R13 had a right heel wound with daily dressing changes. An EBP sign was not posted outside the entrance to R13's room. R13's care plan stated R13 was on universal precautions. R2 had a colostomy. An EBP sign was not posted outside the entrance to R2's room. R2's care plan stated R2 was on universal precautions. R7 had wounds that required daily dressing changes. An EBP sign was posted outside the entrance to R7's room. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R3, R4, and R10) of 3 sampled residents. Staff did not use a gait belt while assisting R3 with a transfer. On 4/4/26, R4 fell out of bed and fractured their right humerus (long bone in the upper arm that extends from the shoulder to the elbow). Staff indicated the bed malfunctioned and/or the mattress moved during cares. An intervention was not added to R4's care plan post-fall. R10 fell on 4/16/26. An intervention was not added to R10's care plan post-fall.

Inspectors wroteBased on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 46 residents residing in the facility. The facility had a COVID-19 outbreak that ended in February of 2026. The facility did not complete N95 fit testing for staff since 2022.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R6, R7, and R9) of 6 sampled residents. Paint, drywall, and plaster compound were left in an unoccupied room that was accessible to residents.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 46 residents residing in the facility. R37 tested positive for Influenza on 1/21/26. There was not a contact/droplet sign or a personal protective equipment (PPE) cart outside R37's room. In addition, staff completed cares without the proper PPE.R2 was on precautions due to a diagnosis of Influenza A. Certified Nursing Assistant (CNA)-L did not don the appropriate PPE and Registered Nurse (RN)-I reused a disposable gown to enter R2's room. In addition, RN-I removed an N95 respirator prior to exiting the room. R43 was on droplet precations due to a diagnosis of Influenza A. [...]

Inspectors wroteBased on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 4 residents (R) (R13, R9, R11, and R2) of 7 sampled residents. R13 did not meet Loeb's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not consulted to determine if the antibiotic should have been continued when R13 did not meet the criteria for a UTI.R9 did not meet Loeb's criteria for a UTI but received antibiotic therapy. The physician was not consulted to determine if the antibiotic should have been continued when R9 did not meet the criteria for a UTI.R11 did not meet Loeb's criteria for a respiratory tract infection but received antibiotic therapy. R2 was prescribed a prophylactic antibiotic. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure proper physician or Power of Attorney for Healthcare (POAHC) notification for 3 residents (R) (R36, R22, and R5) of 12 sampled residents. R36's physician was not notified of an elevated blood pressure on 1/28/26. R36's physician was not notified when R36's pulse was less than 50 on 1/27/25, 1/22/26, 1/21/26, 1/20/26, 1/19/26, 1/17/25, and 1/16/26. In addition, R36's physician was not notified when R36's anti-hypertensive medication was held. R22's physician was not notified when R22's anti-hypertensive medication was held. R5 tested positive for Influenza A on 1/23/26. R5's POAHC was not notified of the positive test or that R5 started Tamiflu.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written Notice of Medicare Non-Coverage (NOMNC) form (which is used to inform residents of their final day of Medicare Part A insurance coverage and standard claim appeal rights and instructions) was thoroughly completed when provided to 3 residents (R) (R57, R58, and R59) of 3 sampled residents. R57, R58, and R59 were issued written NOMNC forms when their Medicare Part A services were ending. The facility did not ensure the forms included all of the required information.

Inspectors wroteBased on observation, staff, resident, and family interview, and record review, the facility did not ensure adaptive equipment to maintain the current level of function and prevent contracture was provided for 1 resident (R) (R6) of 1 sampled resident. R6 did not have rolled towels placed in the left hand and elbow crease and as ordered. In addition, R6's care plan contained an intervention for a left hand splint to be worn at all times. The splint was not consistently applied. Findings Include:The facility's Restorative policy, revised 2/5/25, indicates: It is the guideline of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R20) of 3 sampled residents. Staff did not ensure R20's cigarettes, lighter, and e-cigarette were kept in a secure location. In addition, a smoking evaluation completed for R20 was not accurate and indicated R20 could store smoking materials independently.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary tube feeding services for 1 resident (R) (R7) of 2 sampled residents. Certified Nursing Assistant (CNA)-D turned off R7's tube feeding before it was complete and without checking with a nurse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R36 and R22) of 7 sampled residents. R36's vital signs were not completed on 1/27/26 prior to administering metoprolol and clonidine. R36's vital signs were not completed timely on 1/27/26, 1/22/26, 1/21/26, 1/20/26, 1/19/26, 1/18/26, and 1/17/26 prior to administering and/or holding metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine for a low pulse. R36's physician and standing orders to hold metoprolol and clonidine when R36's pulse was less than 50 were not followed on 1/22/26, 1/21/26, 1/20/26, 1/19/26, and 1/16/26. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure a stock medication was labeled and administerd in accordance with manufacturer's recommendations for 1 resident (R) (R54) and 1 staff (Registered Nurse (RN)-R). On [DATE], the medication room contained Tuberculin Purified Protein Derivative, Mantoux (an injectable solution used for skin testing to diagnose latent tuberculosis (TB) infections) which had a handwritten date of 4/25 or 4/28 on the outer package. Staff confirmed the medication should contain an open date and that once opened, the solution should be used within 30 days. The solution was used to administer TB tests for R54 and RN-R.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment was free from abuse for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff on multiple occasions that Certified Nursing Assistant (CNA)-D was rough with cares and they did not want CNA-D to provide care or enter their rooms. The facility did not implement measures to ensure R3, R5, R6, R10, R11 and other residents were free from abuse.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 5 residents (R) (R3, R5, R6, R10, and R11) of 10 sampled residents. R3, R5, R6, R10, and R11 reported to staff that Certified Nursing Assistant (CNA)-D was rough with cares. The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 6 residents (R3, R1, R5, R6, R10, and R11) of 10 sampled residents. R3 reported an allegation of abuse to Nursing Home Administrator (NHA)-A regarding Certified Nursing Assistant (CNA)-D. The facility did not thoroughly investigate the allegation of abuse. R1's Power of Attorney for Healthcare (POAHC) reported allegations of abuse to the local police department. The facility did not thoroughly investigate the allegations of abuse. R5 and R5's family reported that CNA-D was rough with cares and R5 did not want CNA-D to provide care or enter R5's room. The facility did not thoroughly investigate the allegation of abuse. R6 reported that CNA-D was rough with cares and did not want CNA-D to touch R6. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 of 5 sampled residents (R1) received care and treatment in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) and failed to ensure a change of condition was recognized and acted upon timely. On 8/26/25, R1 complained of increased pain and difficulty breathing. The Nurse Practitioner (NP) was notified and indicated R1 could have additional acetaminophen up to 4000 milligrams (mg) in a 24 hour period in addition to tramadol and could use diclofenac or stock pain reliever for back/shoulder pain. The NP also gave an order to try to wean R1 off oxygen which the NP presumed was used for anxiety/pain and indicated if R1 continued to require oxygen, staff should notify the NP. The orders were not transcribed in R1's medical record at that time. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure notifications were completed in a timely manner following a fall with injury for 1 resident (R) (R1) of 7 sampled residents. R1 incurred a head injury during a Hoyer lift transfer on 11/14/24 when the lift tipped over on R1 and a metal bar struck R1 in the forehead. The facility did not notify R1's Hospice agency until 11/19/24 or R1's physician until 11/21/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 sampled residents. R1 was transferred from bed to Broda chair via Hoyer lift on 11/14/24. Staff did not ensure R1's catheter bag was disconnected from the bed prior to the transfer which created resistance and caused the Hoyer lift to fall and strike R1 in the head. R1 exhibited signs and symptoms of a head injury but was not offered the opportunity to seek medical evaluation at the hospital.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R4) of 4 sampled residents. R4 had an indwelling Foley catheter. Enhanced Barrier Precautions (EBP) were not initiated for R4. In addition, R4's uncovered catheter drainage bag was in contact with the floor during provision of cares on [DATE].

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was prepared in a sanitary manner. This practice had the potential to affect all 34 residents residing in the facility. Staff did not perform proper hand hygiene while plating food. Staff did not wear a beard net that covered all facial hair while plating food. Staff did not check the water temperature of the sanitizing solution prior to testing the parts per million (ppm).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure diet orders and menus were followed to ensure nutritional needs were met for 13 residents (R) (R30, R16, R1, R11, R12, R20, R24, R2, R10, R4, R6, R5, and R7) of 13 residents. During the 9/3/24 lunch meal, the facility served full serving desserts and did not offer diet desserts or ¼ size servings for R30, R16, R1, R11, R12, R20, R24, R2, R10, R4, R6, R5, and R7 who were ordered carbohydrate-controlled diets. During the 9/3/24 lunch meal, the facility did not ensure all menu items were served to residents.

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R26) of 16 sampled residents. R26 was under guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R26's nursing home stay exceeded 60 days.

Inspectors wroteBased on staff, resident, and family interview and record review, the facility did not provide the necessary care and services to prevent and/or promote healing of pressure injuries for 1 resident (R) (R5) of 4 sampled residents. R5's plan of care indicated R5 had left buttock and right sacral moisture-associated skin damage (MASD) and contained an intervention to turn/reposition R5 every 2-3 hours. The intervention was not consistently implemented.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure a cervical collar was implemented per the physician's order for 1 resident (R) (R32) of 1 sampled resident. R32 was admitted to the facility following a neck fracture. During an observation on 9/3/24, R32's cervical collar (neck brace) was on R32's bed. R32 indicated the collar should be on. R32's plan of care did not indicate when R32 should wear the collar or if the collar could be removed.

Inspectors wroteBased on staff interview and record review, the facility did not provide necessary treatment and services related to nutrition for 2 residents (R) (R17 and R13) of 3 sampled residents. R13 was at risk for weight loss and R13's dentures were missing. R13's diet was not altered until the R13's dentures were found. Registered Dietitian (RD)-J was not contacted per the physician's request to review R17's tube feeding when a new medication was started.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection during the provision of care for 2 residents (R) (R12 and R29) of 2 sampled residents. On 9/4/24, staff did not complete proper hand hygiene during medication pass for R12 and R29.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a vaccination was offered for 1 resident (R) (R10) of 5 sampled residents. R10 was not offered the PCV20 vaccination in accordance with Centers for Disease Control and Prevention (CDC) guidelines and the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of misappropriation was reported timely to the State Agency for 1 Resident (R) (R5) of 5 residents reviewed. R5 notified staff that R5's checkbook was missing. Staff did not report R5's missing checkbook to administration who in turn did not report the potential allegation of misappropriation to the State Agency.

Inspectors wrote4. On 7/31/23, Surveyor reviewed R20's medical record. R20's medical record did not contain a written notification of transfer for a hospital transfer on 5/18/23. Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 6 Residents (R) (R23, R32, R47, R20, R15, and R39) of 6 residents reviewed for hospitalization. R23 was not provided a written transfer notice when R23 was transferred to the hospital on 6/5/23, 7/12/23, and 7/26/23. R32 was not provided a written transfer notice when R32 was transferred to the hospital on 7/10/23. R47 was not provided a written transfer notice when R47 was transferred to the hospital on 6/27/23. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure the accurate and safe administration of pharmaceuticals for 5 Residents (R) (R34, R27, R18, R40, and R5) of 5 sampled residents and with the potential to affect all 22 residents residing on the 100 wing. On [DATE], Surveyor intervened before R34 was administered an inaccurate and expired dose of docusate sodium (used to promote bowel movements). On [DATE], R27 was administered an inaccurate and expired dose of docusate sodium. On [DATE], R18 was administered an inaccurate and expired dose of docusate sodium. R40 was administered outdated Artificial Tears (used to treat dry eyes) eye drops from [DATE] through [DATE]. In addition, on [DATE], R40 self-administered six oral medications. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified timely of a change in condition for 1 Resident (R47) of 7 residents reviewed for hospitalization. R47's physician was not notified when there was blood in R47's urine.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy in regard to screening 3 of 8 employees reviewed for background checks. An out of state background check was not completed for Driver (DR)-F who resided in another state within 3 years of hire. Hospitality Aide (HA)-H's Background Information Disclosure (BID) form was not dated. Certified Nursing Assistant (CNA)-G's background check was not completed within the last four years.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 4 errors occurred during 29 opportunities which resulted in a 13.79% medication error rate affecting 2 Residents (R) (R34 and R40) of 3 residents observed during medication pass. On [DATE], Surveyor intervened before R34 was administered an inaccurate and expired dose of docusate sodium (used to promote bowel movements). In addition, on [DATE], R34 was not administered a scheduled dose of Coenzyme Q10 (used to promote heart health in certain patients). On [DATE], Surveyor intervened before R40 was administered an expired dose of Artificial Tears (used to treat dry eyes) eye drops. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure staff performed proper hand hygiene for 1 Resident (R) (R34) of 7 residents observed during the provision of care. During an observation of care for R34 on 8/1/23, Registered Nurse (RN)-M did not consistently perform appropriate hand hygiene.