Rivers Edge Nursing and Rehab: Fall With Fracture - WI
Inspectors documented the injury during an April 2025 survey of the 1000 N. Wisconsin Ave. facility. The violation was classified as causing actual harm, the federal government's designation for deficiencies that result in real injury to a real person, not just the possibility of one.
The resident, identified in inspection records as R17, was attempting to transfer himself when he fell. The facility had not implemented one-on-one supervision or any additional interventions to increase oversight before the fall occurred. By the time inspectors arrived, the fracture had already happened.
The supervision failure was not the only problem inspectors found.
R1, a resident managing Type 2 diabetes with a foot ulcer, morbid obesity, a stage 3 pressure ulcer, muscle weakness, and polyneuropathy, had been charging his power wheelchair inside his own room. On the morning of April 3, an inspector observed the chair plugged into an outlet in R1's room. R1 disconnected it himself and pointed to where he always charged it, the outlet on the wall with the cord hanging from it.
Just under an hour later, the nursing home administrator walked through the room with the inspector. The chair was gone by then, only the cord still attached to the outlet. The administrator looked at it and said the chair should not be charging there. It should be in the charging room, the administrator said. Then the administrator unplugged the cord and took it out of the room.
What the administrator said next is what made the finding a formal deficiency. The facility, the administrator acknowledged, has no policy related to power wheelchair charging.
R1 is cognitively intact. His most recent mental status assessment, completed in February 2025, gave him a perfect score, 15 out of 15, on the Brief Interview for Mental Status. He knew exactly what he was doing and where he was doing it. The facility simply had no written guidance governing how or where power wheelchairs should be charged, which meant no one had formally told R1 otherwise, and no staff member had a written protocol to enforce.
Power wheelchairs carry lithium-ion batteries, which can overheat. Charging them in resident rooms, near beds and furniture and people who may not be able to move quickly, presents a different risk profile than charging them in a designated room built for that purpose. The administrator knew the chair belonged somewhere else. The facility had just never written that down.
These two findings, the fall with fracture and the charging policy gap, came from the same inspection. They sit at different ends of the harm spectrum. One resident already has a fracture. The other has been charging his wheelchair in his room for long enough that it had become routine, long enough that he knew exactly which outlet he used and pointed to it without hesitation.
The fracture is documented. What R17's recovery looks like, whether the injury changed how much he can do for himself, whether it extended his stay, none of that appears in the inspection record. The report states the harm, names the missing intervention, and moves on.
R1 scored perfectly on his cognitive assessment. He understood his situation clearly. He charged his chair where he had always charged it, in a facility that had never told him, in writing, that he couldn't.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 26, 2026 · Our methodology
Rivers Edge Nursing and Rehab in Muscoda, WI was cited for violations during a health inspection on April 21, 2025.
Inspectors documented the injury during an April 2025 survey of the 1000 N.
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.