Fair View Nursing: BP Crisis Unreported to Doctor - WI
That's the sequence documented by a federal inspector at Fair View Nursing and Rehabilitation Center following a complaint investigation completed September 3, 2025.
The resident, identified in the inspection report only as R1, had been on Metoprolol, a beta-blocker commonly prescribed to treat high blood pressure. She was also receiving three blood pressure readings daily, an order that itself signals the facility knew her pressure needed watching. The facility's own electronic health records system was flagging those readings as abnormal, both high and low, across multiple days in late July and early August.
The Metoprolol kept coming anyway. Nurses gave it on July 29 at 7:15 in the evening. Twice on July 30. Twice on July 31. On the morning of August 1 at 8:22 AM, another dose. That afternoon, at approximately 3:35 PM, R1's blood pressure registered at 52 over 40. Staff called a rapid response. She was taken to the emergency department, where she was found to be septic.
The physician who had been managing R1's blood pressure for years, identified as MD C, told the inspector she had received no notification from the facility about any of the low readings. Not one. She said she would have expected a call if R1's systolic pressure dropped below 100. Several of the flagged readings had done exactly that.
"There is an opportunity to improve communication," MD C told the surveyor, a careful phrase that carried significant weight given what preceded it. She said she could have adjusted R1's medications, or discontinued the Metoprolol entirely, had anyone reached out. She also noted that R1 had C. diff, an intestinal infection, which can itself drive blood pressure down. The combination of an active infection and a medication that suppresses the heart's output is the kind of clinical picture a physician needs to know about.
Nobody told her.
The Director of Nursing, identified as DON B, told the inspector that the facility had no specific blood pressure parameters established for R1, and that nurses were expected to use their own judgment about whether a reading was too low or too high. When the inspector asked about the facility's general threshold for a dangerously low blood pressure, DON B said it was 80 systolic.
The facility's own electronic records system had been set to flag anything below 90 over 60. DON B said she was unaware of that.
DON B was also unable to locate the additional blood pressure readings that were part of R1's nursing order, the three-times-daily readings ordered specifically to monitor her condition.
What the inspection report captures, in plain terms, is a system that was generating warnings nobody acted on. The EHR flagged the readings. The order for three daily blood pressure checks existed precisely because R1's pressure needed monitoring. The physician who had managed this patient for years, before she even arrived at the facility, had a clear expectation of being notified. None of those mechanisms produced a phone call.
The violation was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. Whether that designation accounts for the sepsis hospitalization is not addressed in the report.
MD C, when asked directly what might have happened if she had been notified earlier, said it was hard to say for sure. That uncertainty, offered honestly by the doctor who knew this patient best, is its own kind of answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair View Nursing and Rehabilitation Center from 2025-09-03 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: July 23, 2026 · Our methodology
FAIR VIEW NURSING AND REHABILITATION CENTER in MAUSTON, WI was cited for violations during a health inspection on September 3, 2025.
The resident, identified in the inspection report only as R1, had been on Metoprolol, a beta-blocker commonly prescribed to treat high blood pressure.
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.