Rivers Edge Nursing: Bed Rail Safety Failures - WI
Rivers Edge Nursing and Rehab failed to follow basic safety protocols for bed rails, medications, food service, and infection control during a federal inspection in April. The violations put dozens of residents at risk across multiple areas of care.
The most widespread problem involved bed rails used by at least six residents. Staff never measured gaps between rails and air mattresses that could trap residents' heads or bodies. They skipped entrapment assessments. They provided no documentation of alternatives tried before installing the rails.
One resident with Parkinson's disease and severe cognitive impairment had rolled out of bed at 1:31 AM in August 2024. Despite this fall, staff never updated his bed rail safety assessment or measured gaps with his air mattress.
"We messed up," one nursing assistant told inspectors after being observed transferring a catheter patient without gloves or gown. The resident required enhanced barrier precautions specifically because of her indwelling catheter.
Missing Safety Measures
The facility's own policy required comprehensive assessments before installing bed rails, including evaluation of residents' medical conditions, size, weight, sleep habits, and medications. Staff were supposed to document alternatives attempted and assess entrapment risks.
None of this happened for the residents reviewed.
A 67-year-old woman with osteoarthritis and muscle wasting told inspectors she never received education about bed rail risks and benefits. Her family member confirmed no one had discussed the dangers with them either.
Another resident with breast cancer that had spread to her bones said she couldn't recall receiving any bed rail education due to memory issues from her treatment. Her family member also reported receiving no information about risks.
The maintenance director admitted he had never measured gaps between mattresses and bed rails to prevent entrapment. He said nursing staff should handle those assessments. The director of nursing said maintenance should do the measurements.
"That would be maintenance," Director of Nursing B told inspectors when asked who was responsible for measuring gaps and ensuring proper bed dimensions for each resident's size and weight.
But Maintenance Director M said he had never completed such measurements and kept no documentation of bed rail inspections, despite conducting weekly facility walk-throughs.
Delayed Antibiotic Treatment
A diabetic resident with dementia developed cellulitis in his right third toe and went to the emergency room on March 6. The ER doctor prescribed Keflex antibiotic to be taken four times daily for seven days.
The facility didn't enter the order into the resident's medication record until March 7 and didn't give him his first dose until March 8 — a two-day delay for treating an infection.
The interim director of nursing told inspectors that physician orders should be processed within 24 hours, though she acknowledged that wasn't very expedient. She said new orders weren't always seen right away by staff.
The facility physician explained that orders placed by 5 PM would be delivered by pharmacy that night, while later orders arrived the next day. But the resident's antibiotic order sat unprocessed for a full day after the ER visit.
Food Safety Violations
Kitchen staff served milk at dangerous temperatures during both breakfast and lunch. The breakfast milk measured 53.2 degrees and tasted warm. Lunch milk reached 48 degrees. Both temperatures fell in the danger zone well above the required 41 degrees or less.
Inspectors found opened milk containers with no date labels, mandarin oranges removed from original packaging without expiration dates, opened barbecue sauce unlabeled, and five thawed dessert cups with no thaw dates.
The dietary manager admitted she didn't know when any of these items had been opened or thawed. She acknowledged that all opened food and drink needed date labels, and magic cups required thaw dates.
"All food or drink that is opened needs to be labeled with open dates," she told inspectors, but couldn't explain when the violations had occurred.
Infection Control Breakdowns
Two nursing assistants transferred a resident with enhanced barrier precautions from her wheelchair to the toilet without wearing required protective equipment. The resident had a catheter and needed a mechanical lift for transfers.
The assistants handled the catheter bag, removed the resident's clothing, and positioned her on the toilet without gloves or gowns. Both washed their hands afterward but acknowledged they should have worn protective equipment throughout the process.
"We messed up," one assistant said. "I should have worn gloves and a gown when providing close contact cares like moving the catheter and transferring."
In another case, the interim director of nursing removed a wound dressing from a resident's right leg without wearing a gown, despite facility policy requiring full protective equipment for wound care under enhanced barrier precautions.
When questioned, she initially said gowns were only needed for positive wound cultures or excessive drainage. But the vice president of clinical services and nursing home administrator both confirmed that gowns and gloves were required for all wound dressing removal under enhanced barrier precautions.
Contradictory Expectations
The director of nursing told inspectors that bed rail assessments should be completed quarterly, "but they hadn't been completed since last May." She said quarterly assessments were her expectation, yet no staff had conducted them for nearly a year.
She claimed residents and families were told about bed rail risks and benefits but had no documentation of these discussions. When inspectors asked what specific risks were explained, she said she thought there was something but couldn't find it.
The facility's policy required written documentation of ongoing bed rail monitoring, safety tests with air mattresses, and evidence of alternatives tried before installation. None of the six residents reviewed had any of this documentation.
Staff consistently pointed fingers at other departments. Nursing said maintenance should measure gaps and assess bed dimensions. Maintenance said nursing should handle resident assessments. Neither department was doing the required safety work.
The inspection found violations affecting food service for all 41 residents, with the potential for medication errors and infection control failures extending to additional residents beyond those specifically documented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rivers Edge Nursing and Rehab from 2025-04-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Rivers Edge Nursing and Rehab in Muscoda, WI was cited for violations during a health inspection on April 21, 2025.
The violations put dozens of residents at risk across multiple areas of care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Rivers Edge Nursing and Rehab?
- The violations put dozens of residents at risk across multiple areas of care.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Muscoda, WI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Rivers Edge Nursing and Rehab or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525321.
- Has this facility had violations before?
- To check Rivers Edge Nursing and Rehab's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.