Rivers Edge Nursing and Rehab: Missed Foot Checks - WI
The resident, identified in inspection records as R16, is a cognitively intact man living at the facility with Type 2 diabetes, dementia, and a serious ankle fracture involving his right tibia, fibula, and medial malleolus. His physician ordered nightly foot checks at bedtime starting July 2024. The checks were meant to catch exactly the kind of problems that diabetic patients cannot always feel themselves: wounds, skin breakdown, early signs of infection.
Thirteen times between January and March 2025, nobody completed the check.
In January, staff skipped three consecutive nights, the 16th, 17th, and 18th. In February, the checks were missed on six separate days. In March, they were missed on four more. The gaps were documented in the facility's own Treatment Administration Records, the logs nurses sign to confirm care was given.
On April 16, an inspector sat down with LPN W, one of the nurses responsible for the checks. LPN W said that if the order was on the TAR, she would have completed it. When the inspector asked directly whether she had done foot checks for R16, she said yes. When asked if she could recall anything specific about his feet, any wounds or open areas, she could not.
Then she offered an explanation for why the checks were sometimes rushed. R16, she said, would become agitated when staff approached him while he was in bed. So the checks were often hurried. Not as thorough as they should be.
What she did not explain was the four days in March.
A podiatrist had placed a gauze dressing on R16's foot on March 14. When podiatry returned for a follow-up appointment on March 18, the same dressing was still there. It had not been changed. LPN W had signed the TAR indicating she completed foot checks on March 15 and March 16. She told the inspector she could not recall any concerns about R16's foot on either of those dates.
If she had looked closely enough to sign the record, she had looked at a foot with a dressing that needed attention. She did not document it. She did not recall it.
The Interim Director of Nursing, identified as IDON X, told the inspector the following day that she would expect foot checks to be completed as ordered and signed out accurately. She said that if anything unusual was found, a progress note would reflect it.
There were no progress notes.
The facility's administrator confirmed to the inspector that nightly foot checks were expected. The inspection report categorized the violation as causing minimal harm or potential for actual harm, affecting a small number of residents.
For a diabetic patient, that framing carries weight. Diabetic neuropathy can mask pain from wounds or pressure injuries, meaning a foot problem that goes unnoticed for days can advance quickly. The ordered check existed precisely because R16 could not be relied upon to notice or report a problem himself.
What the records show is that the check was skipped on thirteen nights across three months, that a nurse signed off on checks during a window when a bandage sat untouched on the resident's foot, and that when asked to account for what she found during those checks, she had nothing to say.
R16's condition during those missed nights is not described in the inspection report. Whether his foot healed without complication, or whether something was missed, the records reviewed by the inspector do not say.
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.
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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.
His physician ordered nightly foot checks at bedtime starting July 2024.
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.