Wisconsin Rapids Health Services

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was stored, prepared, and served in a safe and sanitary manner. This practice had the potential to affect 35 of 36 residents residing in the facility (one resident received nutrition via tubefeeding.)Staff did not complete appropriate hand hygiene. Documentation logs for parts per million (PPM) of the sanitizing solution were not completed correctly. Staff did not follow safe food cooling protocols. Food was not served at an appropriate temperature.

Inspectors wroteBased on staff interview and record review, the facility did not provide a bed hold or transfer notice and/or notify the state long-term care Ombudsman of hospital transfers for 2 residents (R) (R19 and R21) of 5 sampled residents. R19 was transferred to the emergency room (ER) on 9/25/25, 10/5/25, and 1/8/26. R19 was not provided a written bed hold or transfer notice for the hospital transfers on 9/25/25 and 1/8/26. In addition, the Ombudsman was not notified of any of the transfers. R21 was transferred to the ER twice on 1/18/26. The Ombudsman was not notified of the transfers.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions to a high risk medication for 1 resident (R) (R32) of 5 sampled residents. R32 had an order for Apixaban (an anticoagulant) 5 milligrams (mg) two times daily for cerebrovascular accident (CVA). The facility did not monitor R32 for adverse reactions to the high-risk medication. In addition, R32 did not have a care plan related to anticoagulant use.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored in a safe and sanitary manner and the kitchen was in a clean condition. This practice had the potential to affect 20 of the 36 residents who resided on the second floor. Two cabinets in the kitchenette next to the dining room contained mouse droppings. The facility did not have documentation to indicate the last time the cabinets were cleaned. The refrigerator in the kitchenette next to the dining room contained unlabeled, undated, and/or expired food items.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R7) of 2 sampled residents. R8 reported to staff on 9/3/25 that Certified Nursing Assistant (CNA)-E yelled at R7 (who was R8's spouse). The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of verbal abuse was thoroughly investigated for 1 resident (R) (R7) of 2 sampled residents. R8 reported to staff on 9/3/25 that Certified Nursing Assistant (CNA)-E yelled at R7 (who was R8's spouse). The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R1 and R6) of 2 sampled residents were provided safe and accurate administration of drugs and biologicals. Registered Nurse (RN)-K did not administer R1's Ozempic as ordered. In addition, RN-L documented Ozempic was administered to R1 when it was not administered. During the administration of insulin for R6, RN-C held a lispro injectable pen to R6's skin for less than the recommended 5 to10 seconds.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure mechanical lifts were in safe operating condition which affected 1 resident (R) (R1) of 2 sanpled residents. R1 required a bariatric lift to transfer to an electric wheelchair. From 9/20/25 to 9/23/25, R1 was unable to transfer out of bed when the facility's bariatric Hoyer lift was out of service. In addition, staff had shared remotes between bariatric lifts for 2 weeks prior and a bariatric EZ stand lift was not in working order.

Inspectors wroteBased on staff interview and record review the facility did not ensure a physician was notified regarding a change in condition for 1 resident (R) (R1) of 3 sampled residents. R1's medical record indicated R1 refused at least 2 meals per day multiple days in March 2025. The facility did not notify R1's physician of the refusals.

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 2 residents (R) (R3 and R4) of 3 residents observed during the provision of cares. Certified Nursing Assistant (CNA)-G did not complete appropriate hand hygiene during the provision of care for R4. Licensed Practical Nurse (LPN)-E and CNA-F did not wear the appropriate personal protective equipment (PPE) during a transfer for R3 who was on enhanced barrier precautions (EBP).

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a medical record contained signed COVID-19 vaccination documentation for 1 resident (R) (R2) of 5 sampled residents. R2's medical record did not contain a signed authorization from R2's Power of Attorney for Healthcare (POAHC) for the facility to administer a COVID-19 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R1) of 5 sampled residents. A grievance was emailed to the facility on [DATE] that indicated certain medications were not administered to R1 during R1's respite stay. The grievance was not investigated and a resolution was not provided.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 of 4 residents (R) reviewed for pressure injuries (PI) (R151 and R32) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R151 was admitted to the facility with a sacral PI and was assessed to be at risk for PI development. R151 developed one unstageable PI on 10/16/24 and three unstageable PIs on 10/18/24. R151's care plan for PI interventions was not developed until 10/18/24 and not updated until 10/23/24 with interventions to off-load pressure areas to R151's bilateral lower extremities and sacral wound. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure food was prepared in a clean and sanitary environment which had the potential to affect over 75% of the 48 residents (R) in the facility as 2 of the residents received tube feeding. Staff did not consistently test or document parts per million (PPM) of the sanitizing solution. Staff did not consistently document refrigerator temperatures. This was evidenced by: Sanitization Solution: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. [...]

Inspectors wroteBased on interview and record review, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman for 4 of 4 residents (R) reviewed who were discharged to hospital (R12, R35, R50, and R4). The Ombudsman was not notified when R12, R35, R50, and R4 were discharged /transferred to the hospital. This was evidenced by: Example 1 R12 was hospitalized from [DATE] to 7/22/24, 7/29/24 to 8/2/24, and 8/7/24 to 8/16/24 for a change in condition. On 10/23/24 at 1:42 PM, Surveyor requested information of notification to the State Long Term Care Ombudsman for R12's discharges to the hospital. Director of Nursing (DON) B stated the facility did not have documentation of the notices. [...]

Inspectors wroteExample 4 R151 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, left side, chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 3, personal history of transient ischemic attack, peripheral vascular disease (PVD), congestive heart failure, prediabetes, and cardiac pacemaker. An admission MDS assessment, dated 10/16/24, documented a BIMS score of 12 out of 15 which indicated R151 had moderately impaired cognition. The MDS documented R151 had impairment to both lower legs and required partial/moderate assistance of staff for toileting and upper and lower body cares. R151 had a physician order dated 10/13/24 for Enhanced barrier precautions d/t (due/to) open wounds. Every shift for wound care. On 10/22/24 at 9:22 AM, Surveyor observed Registered Nurse (RN) H provide wound care for R151's feet. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident (R) was treated with dignity and respect and cared for in a manner that enhanced their quality of life for 2 residents (R16 and R24). Staff were observed feeding R16 and R24 part of their meals while standing over them. This was evidenced by: The facility policy titled The Dining Experience: Staff Responsibilities, dated 4/10/20, states in part: The dining experience will enhance each individual's quality of life through person centered dining. Example 1 R24 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and anemia. R24's care plan states in part: Eating - assist with set up. Encourage and assist as needed to consume foods and/or supplements and fluids offered. On 10/22/24 at 8:39 AM, Surveyor observed R24 trying to eat her meal. [...]

Inspectors wroteBased on interview and record review, the facility did not complete and submit a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days after determining a SCS had occurred for 1 of 15 residents (R) (R48) reviewed. R48 was admitted to Hospice services on 6/24/24. A Significant Change MDS assessment was not completed. This was evidenced by: R48 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy ischemic, hypertension, and congestive heart failure. In reviewing the medical record of R48, Surveyor noted the most recent MDS assessment completed was a Medicare - 5 day assessment dated [DATE]. R48 was admitted to Hospice services on 6/24/24. A Significant Change MDS assessment had not been completed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented for each resident (R) within 48 hours of admission for 1 of 14 residents reviewed (R49). R49 was admitted to the facility on [DATE]. A baseline care plan was not implemented in a timely manner. This was evidenced by: R49 was admitted to the facility on [DATE] and was discharged on 8/9/24. R49's diagnoses included encounter for other orthopedic aftercare, diabetes mellitus type 2, weakness abnormalities of gait and mobility, emphysema, cervical disc disorder with myelopathy, hypertension, paroxysmal atrial fibrillation, anxiety disorders, behavioral and emotional disorder, social phobia, stress incontinence, history of malignant neoplasm of breast, and nicotine dependence. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive care plan for each resident (R) to meet medical, nursing, and psychosocial needs identified for 2 of 15 sampled residents (R35 and R23). R35 did not have a sleep hygiene care plan developed when R35 was prescribed medication to promote sleep. R23 did not have a comprehensive care plan for skin integrity. This was evidenced by: The facility's policy titled Comprehensive Care Plan, revised 9/23/22, states in part: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment .5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident (R) who was discharged from the facility received a discharge summary that included a recapitulation of the resident's stay for 1 of 1 residents reviewed (R49). R49 was discharged from the facility on 8/9/24. R49's medical record did not contain a recapitulation of stay. This was evidenced by: R49 was admitted to the facility on [DATE] with diagnoses of other orthopedic aftercare, diabetes mellitus type 2, weakness abnormalities of gait and mobility, emphysema, cervical disc disorder with myelopathy, hypertension, paroxysmal atrial fibrillation, anxiety disorders, behavioral and emotional disorder, social phobia, stress incontinence, history of malignant neoplasm of breast, and nicotine dependence. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents (R) who were fed by enteral means received the appropriate treatment to prevent complications for 1 of 2 residents (R40) observed for enteral feeding. R40 received nutrition via enteral feeding. Staff did not ensure R40's gastronomy (G)-tube was appropriately placed prior to the administration of flushes and feedings. This was evidenced by: The American Association of Critical Care Nurses, April 2016, Initial and Ongoing Verification of Feeding Tube Placement in Adults advises: Unfortunately, feeding tubes can become dislocated during use. For this reason, it is necessary to monitor tube location at regular intervals while the tube is being used for feedings or medication administration. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of insulin for 1 of 1 resident (R) (R25). R25 was prescribed insulin. During an observation on 10/23/24, staff drew insulin from a pre-filled insulin pen to administer to R25. This was evidenced by: The facility's policy titled Medication Administration - Subcutaneous Insulin, dated 1/2023, did not indicate if using an insulin syringe to draw insulin out of a pre-filled insulin pen was appropriate. The Institute for Safe Medication Practices: Guidelines for Optimizing Safe Subcutaneous Insulin Used in Adults states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed and had non-pharmacological interventions implemented to determine adequate indication for use of the medication for 1 of 5 residents reviewed (R35). R35 received trazodone (an antidepressant medication) for insomnia. The facility did not implement monitoring interventions to determine the effectiveness of the medication. This was evidenced by: The facility's policy titled Psychotropic Medications, with a reviewed/revised date of 10/24/22, reads in part: 2. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of non-pharmacological approaches, will be determined by: a. Assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. b. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored in a sanitary manner and labeled/dated appropriately. This practice had the potential to affect multiple residents residing in the facility. Staff did not date items with open or expiration dates and did not ensure food was stored in a sanitary manner. Staff did not ensure supplement shakes were dated when removed from the freezer and thawed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 3 residents (R) (R2, R7 and R9) of 12 sampled residents received necessary and timely assistance with activities of daily living (ADLs). R2 was dependent on staff for bathing. R2 did not receive a shower as scheduled. R7 had an order for weekly diabetic nail care. The facility did not provide consistent nail care and/or revise R7's order to provide nail care more frequently. During an observation on 6/27/24, staff did not respond to R9's call light and request to get out of bed in a timely manner.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure necessary care and services were provided to promote healing and/or prevent pressure injuries from worsening/developing for 2 residents (R) (R1 and R7) of 3 sampled residents. During an observation on 6/27/24, Registered Nurse (RN)-F did nnot perform appropriate hand hygiene during wound care for R1 and Surveyor noted care planned pressure relieving measures were not in place. In addition, R1's medical record did not contain appropriate wound assessment documentation and timely response to newly opened areas. R7 had a history of a pressure injury on the left heel. R7's care plan contained an intervention to float/elevate R7's heels. The intervention was not consistently implemented.

Inspectors wroteBased on staff interview and record, the facility did not ensure 2 residents (R) (R3 and R5) of 3 sampled residents received the necessary care and treatment for respiratory therapy. The facility provided R3 with respiratory therapy via continuous positive airway pressure (CPAP) without a physician's order. In addition, R3 was ordered to have bilevel positive airway pressure (BiPAP), but the facility did not obtain the appropriate equipment. R5 had a physician's order for CPAP therapy. R5 did not have a care plan that addressed R5's need for and use of CPAP therapy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R4) of 4 sampled residents. R4 received an incorrect medication due to a transcription error. In addition, R4 did not receive medication doses ordered by R4's physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure code status was determined for 1 Resident (R) (R1) of 2 sampled residents which led to the failure to perform cardiopulmonary resuscitation (CPR) for the resident after the resident was found pulseless and non-breathing (PNB). R1's Power of Attorney for Healthcare (POAHC) document indicated R1 wished to be resuscitated. On [DATE], staff did not initiate resuscitation efforts when R1 was found PNB. R1 passed away at the facility on [DATE]. The facility's failure to ensure code status was determined and perform CPR when R1 was found PNB created a finding of Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 4:46 PM. [...]

Inspectors wroteBased on staff interview and record, the facility did not ensure 2 Residents (R) (R1 and R5) of 3 residents received the necessary care and treatment for respiratory therapy. The facility provided R1 with respiratory therapy via CPAP (continuous positive airway pressure) without a physician's order. In addition, R1's need for and use of CPAP treatment was not care planned for assessment, evaluation, or monitoring. The facility provided R5 with respiratory therapy via CPAP, however, staff did not clean R5's CPAP equipment in accordance with the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment in accordance with professional standards of practice was provided for 1 Resident (R) (R1) of 9 sampled residents. R1 experienced a change in condition, including altered mental status, on the [DATE] AM shift. The facility did not complete an appropriate assessment or notify a physician. EMS (Emergency Medical Services) was notified at 8:50 PM when R1 was found unresponsive. R1 was transferred to the hospital and passed away on [DATE]. The facility's failure to complete an appropriate assessment and timely notify a physician for a resident who experienced a change in condition created a finding of immediate jeopardy that began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 5:14 PM. [...]

Inspectors wroteBased on record review and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 35 residents that reside in the facility. Review of staff posting hours revealed that the facility did not always use the services of an RN for at least 8 hours a day, for 3 of the days reviewed. This is evidenced by: The facility policy, entitled Nursing Services Registered Nurse, dated 07/22/22, states: .The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week . On 08/02/23, Surveyor requested and reviewed the months of October, November, December 2022, April, May, June, and July 2023 staff postings which document staff hours worked for nursing staff. [...]

Inspectors wroteBased on observations and interview, the facility failed to 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 practice had the potential to affect 8 residents R25, R8, R24, R38, R26, R18, R29, and R92 residing in the facility. The facility did not provide hand hygiene to residents R25, R8, R24, R38, R26, R18, R29, and R92 before eating meals. This is evidenced by: The facility policy, entitled Dining Experience, dated 07/27/22, states: .Individuals will be provided with proper hand hygiene prior to each meal or snack . On 07/31/23 at 11:59 AM, Surveyor observed Certified Nursing Assistant (CNA) D serving lunch trays to the following residents who ate in their room: R18, R26, R29, R38. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 1 residents (R23) reviewed for Pressure Injuries (PI) received care consistent with professional standards of practice to promote healing and prevent infection of existing PIs. R23 has a healing stage III PI on her coccyx that was present upon admission. A treatment was observed of this wound in which improper hand hygiene was observed during the dressing changes. Furthermore, the treatment was completed incorrectly and not according to the physician orders (PO). This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 resident (R24) reviewed. The facility did not ensure R24 was administered insulin appropriately based on the observation of the Registered Nurse (RN) not priming the insulin pen before administration. This is evidenced by: The facility policy, entitled Medication Administration Subcutaneous Insulin, dated 01/23, states: .Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles . The manufacturer's instructions for the Insulin injection KwikPen states: [...]