Rivers Edge Nursing and Rehab: Wound Neglect Leads to MRSA - WI
The April 21 federal inspection of Rivers Edge Nursing and Rehab, located at 1000 N. Wisconsin Ave. in Muscoda, resulted in an Immediate Jeopardy citation, the most serious level of harm federal inspectors can assign. It means inspectors determined the facility's failures had placed the resident in a situation likely to cause serious injury or death.
The resident, identified in inspection records only as R18, arrived at the emergency department on April 15. The ED's chief complaint documentation was direct: the guardian believed R18 had developed a wound that was not being attended to at the care facility, and when it was not improving, the guardian wanted him evaluated for further workup and management.
Inspectors were not the ones who escalated this. A family member was.
At the hospital, lab work showed elevated ESR and CRP levels, two markers that measure inflammation in the body. His white blood cell count was normal, which meant the infection had not yet spread systemically, but the wound itself told a different story. Emergency physicians diagnosed cellulitis around the wound and administered Ceftriaxone, an antibiotic, before admitting him. The admitting wound was classified as a grade 2 decubitus ulcer.
Then the culture results came back. The wound had grown MRSA, methicillin-resistant Staphylococcus aureus, a bacterial infection that resists most common antibiotics and is notoriously difficult to treat once established.
The hospital's history and physical from that same day described the ulcerations as chronic in appearance, with redness and warmth around them, consistent with active infection. Physicians noted R18 had a history of venous insufficiency but assessed the wound's characteristics as more arterial in nature. An arterial ultrasound came back normal. Doctors recommended evaluation by a vascular surgeon.
An x-ray of the right tibia and fibula, the lower leg bones beneath the wound, showed no evidence of osteomyelitis, bone infection, and no subcutaneous gas, which would have signaled a deeper, more catastrophic infection. Those results offered some reassurance. But the MRSA culture was not reassuring. It was a finding that documented what had been allowed to develop inside a wound that, according to R18's own guardian, had been going unattended at Rivers Edge.
The inspection report truncates the physician notes from April, so the full clinical timeline of how long the wound existed before hospitalization, and what treatment if any the facility had provided, is not completely visible in the public record. What is visible is the outcome: a resident left a nursing home in an ambulance, was admitted to a hospital, and was found to have a drug-resistant bacterial infection in a wound his guardian had been watching worsen.
Immediate Jeopardy citations require a facility to remove the threat to resident safety before inspectors will close out the finding. They carry the possibility of federal fines and, in cases where the jeopardy is not corrected, termination from Medicare and Medicaid.
Rivers Edge Nursing and Rehab is a small facility serving Muscoda, a rural community in Grant County in southwestern Wisconsin. For R18, the nearest hospital required his guardian to push for a trip he should not have had to fight for.
The guardian's account, recorded in the emergency department's own intake notes, is the document that most clearly describes what happened: a wound developed, it was not being attended to, it was not improving, and the person responsible for R18's wellbeing had to intervene to get him care. By the time he reached the ED, the wound had already grown MRSA.
He was admitted for treatment. The infection was there before the inspectors arrived.
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 neglect violations during a health inspection on April 21, 2025.
The April 21 federal inspection of Rivers Edge Nursing and Rehab, located at 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.