Rivers Edge Nursing and Rehab: Wound Care Failures - WI
The resident, identified in inspection records as R15, had a right heel pressure ulcer first documented on March 24 at 0.5 centimeters by 0.5 centimeters. It was already unstageable, meaning inspectors and wound care staff could not determine how deep the damage went. Within three weeks, that wound had expanded to 4.5 centimeters by 11.2 centimeters. By the time a surveyor stood at R15's bedside on April 17 and measured it directly, the wound bed was 5 centimeters long and 2.5 centimeters wide, with a pale center and slough around the edges.
R15 left the building twice during that stretch. His son gave consent on April 7 for an emergency department evaluation, and R15 returned from a hospital in a nearby town two days later. He had also been transported for evaluation on March 31, when his wound assessment that week was cut short because of acute respiratory distress. Staff documented that the wound visit was abbreviated both times for the same reason.
Nobody assessed his skin when he came back either time.
The facility's own nurses said that wasn't supposed to happen. On the morning of April 17, a registered nurse told the surveyor that a skin assessment and wound evaluation are completed when a resident returns from the hospital. The Interim Director of Nursing said the same thing, then pulled up R15's chart and confirmed there was no assessment documented for April 4 or April 9, the dates of his returns. When the surveyor asked directly whether staff was expected to perform a skin assessment when R15 came back, the Interim Director said yes.
The Nursing Home Administrator, interviewed that same afternoon, said yes as well.
Three people in clinical leadership, all agreeing on what the protocol required. None of them could point to a record showing it was done.
The wound care consultant rounds weekly with a facility nurse, according to the Interim Director. If a resident isn't available during those rounds, the consultant picks up the assessment the following week. That explanation accounts for a gap of seven days. R15's records show no wound documentation at all for April 4 or April 9. The inspection report notes this explicitly: there is no documentation of assessments on either date when R15 returned from the hospital.
Between March 24 and April 14, the wound grew from a half-centimeter square to more than four centimeters across its longest point. The March 31 and April 7 wound visit reports each contain the same notation: no measurements obtained, assessment abbreviated due to respiratory distress. The April 14 report shows the full dimensions of what the wound had become.
Inspectors rated the harm level as minimal or potential for actual harm. R15's wound, by the time the surveyor measured it on April 17, had pale tissue at its center and slough at its edges, markers of a wound that had been progressing without consistent monitoring.
The inspection was completed April 21, 2025.
What the record does not contain is any documentation that anyone checked R15's skin the morning he came back from the hospital, or the morning after, or the day after that.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
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 resident, identified in inspection records as R15, had a right heel pressure ulcer first documented on March 24 at 0.5 centimeters by 0.5 centimeters.
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.