Amethyst Health of Wausau: Pain Med Errors During Wound Care - WI
The resident, identified in inspection records only as R1, had two separate hydrocodone orders. One called for two tablets before wound care, once a day, specifically to prevent pain during the procedure. The other, a single tablet of hydrocodone 5-325 mg, was prescribed every four hours as needed for pain unrelated to wound care. The orders were distinct, with different purposes and different doses.
Nurses gave the wrong one.
The Interim Director of Nursing reviewed the orders with inspectors on the evening of August 19 and confirmed the single-tablet prescription was not intended for wound care preparation. When inspectors asked directly whether nurses had followed what are called the six rights of medication administration, a basic checklist that covers the right resident, right drug, right dosage, right time, right route, and right documentation, the IDON's answer was unambiguous. "No," she said. "They did not."
The wound care itself had been ordered at times up to twice a day. The two-tablet pre-procedure dose was approved for once daily use. The IDON acknowledged that if a nurse saw R1 experiencing uncontrolled pain during a second wound care session, the correct response was to contact the prescribing provider and request a dosage change. There is no indication in the inspection record that nurses did that either.
Licensed Practical Nurse 2, interviewed earlier the same afternoon, said staff tried to schedule wound care while residents were still awake. She said she could not remember any physician ordering wound care for R1 at times after midnight. What she did not address, and what the inspection record makes clear, is that the medication error was not about timing. It was about which order nurses reached for and why.
Wound care is among the more painful routine procedures in a nursing home setting. The two-tablet hydrocodone order existed precisely because the facility and the prescribing physician recognized that. Giving a lower, unrelated dose instead did not simply represent a paperwork error. For the duration of those procedures, R1 had less pain coverage than the physician had determined was necessary.
Federal inspectors rated the violation at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory floor, not a judgment that the error was inconsequential. A resident with wounds serious enough to require scheduled, recurring care, with a physician who felt the pain warranted a dedicated pre-procedure narcotic, received something else instead, on more than one occasion, without any documented attempt to notify the provider.
Amethyst Health of Wausau, located at 1010 East Wausau Avenue, was inspected August 19, 2025, following a complaint.
The IDON said nurses who saw uncontrolled pain during wound care should have called the provider. The inspection record does not indicate any such calls were made. It also does not indicate anyone noticed the error until inspectors arrived and started asking questions.
R1's wound care continued in the meantime.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Amethyst Health of Wausau from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
AMETHYST HEALTH OF WAUSAU in WAUSAU, WI was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records only as R1, had two separate hydrocodone orders.
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.