Rivers Edge Nursing and Rehab: Infection Control Failures - WI
That's what a federal inspector observed on the morning of April 17 at Rivers Edge Nursing and Rehab, a facility in this small Grant County community along the Wisconsin River. The inspection, completed April 21, documented two residents whose infection control protections weren't followed — and a clinical leadership team that couldn't agree on what those protections required.
The resident, identified in inspection records as R15, had been admitted with a pressure ulcer on the right heel, chronic venous hypertension with leg ulcers, and varicose veins that had produced additional wounds on the lower leg. The care plan, in place since July 2024, was explicit: staff were to wear appropriate PPE for any wound-related care.
The interim director of nursing, identified as IDON X, handled the bandage wrap and set the leg down before going into the bathroom and putting on a single pair of gloves. She then removed the border dressing to examine the wound.
When the surveyor asked whether PPE was required for dressing removal, IDON X said yes, gloves. Asked about a gown, she said no, not unless the resident had a positive wound culture or excessive drainage.
That answer contradicted what her own supervisor said thirty-three minutes later.
VPC S, the facility's Vice President of Clinical, told the inspector that enhanced barrier precautions required gowns and gloves whenever staff were touching the resident. Asked directly whether a gown and gloves were required for removing R15's wound dressing, VPC S said yes.
The nursing home administrator, NHA A, gave the same answer when asked that afternoon. Yes, staff are expected to wear a gown and gloves for wound dressing removal on a resident under enhanced barrier precautions.
Three people in clinical leadership. Three confirmations that what the interim director of nursing did that morning was wrong. The interim director of nursing was the one doing the wound care.
The second resident, identified as R2, had a catheter and was also on enhanced barrier precautions. A certified nursing assistant, identified as CNA U, told the inspector on April 16 that she knew she should have worn PPE when providing care for R2, including during transfers, and that she had not.
Enhanced barrier precautions are a targeted infection control measure used for residents who carry or are at risk for certain resistant organisms. The precautions are designed to prevent transmission to other residents and to protect staff. When a facility places a resident on enhanced barrier precautions, it is acknowledging that ordinary contact carries elevated risk.
At Rivers Edge, that acknowledgment was written into care plans. It was stocked onto a cart outside the door. It was understood by the Vice President of Clinical, the administrator, and at least one nursing assistant who knew she hadn't followed it. The gap was in what actually happened when staff entered the room.
The surveyor's notes don't record any explanation for why IDON X handled the wound dressing without a gown, or why CNA U provided catheter care without PPE. CNA U said she should have worn it and didn't. IDON X appeared to believe, until corrected, that she had done nothing wrong.
The violations were cited at the level of minimal harm, affecting few residents. That designation reflects the outcome documented in the inspection record. It does not reflect what the residents were exposed to before the surveyor walked in.
R15's wounds had been on the care plan since at least July 2024. The cart with the PPE was already in the hallway.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
The care plan, in place since July 2024, was explicit: staff were to wear appropriate PPE for any wound-related 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.