Rib Lake Health Services: PPE Failures During GI Outbreak - WI
A federal surveyor watched the whole thing happen at 8:05 a.m.
CNA H went into the room of Resident 5, then Resident 6. Both were on contact precautions for GI illness. CNA H wore no required protective equipment for either visit. Then CNA H walked into Resident 11's room, who was not on contact precautions, and delivered a tray. CNA G did the same thing, entering the rooms of Resident 7 and Resident 9, both on contact precautions, without a gown or gloves. Then CNA G handed food to Resident 12, who was not sick.
Neither CNA used protective equipment before entering any of the five isolation rooms.
Contact precautions exist for exactly this scenario. When a resident is sick with something that spreads through direct or indirect contact, staff are supposed to gown and glove before they cross the threshold, whether they're providing hands-on care or simply setting down a food tray. The facility's own written policy, dated September 24, 2024, says as much. The Director of Nursing said as much when the surveyor interviewed her that morning. The Assistant Director of Nursing said as much two hours later. Both CNAs, when asked, said as much themselves.
CNA H told the surveyor that contact precautions apply "including when passing trays," then added: "I missed one today."
It wasn't one. The surveyor had watched CNA H enter two isolation rooms without PPE before delivering to a resident who wasn't on precautions.
CNA G's account was similar. When the surveyor asked whether she had worn a gown to deliver breakfast trays and whether she should have, CNA G said: "Probably not, I didn't think to do it until I went into R7's room."
R7 was the second isolation room CNA G entered that morning. She had already gone into Resident 7's room without protection before it occurred to her.
The Assistant Director of Nursing told the surveyor the unit was in lockdown because of the five residents with GI symptoms. Fourteen people live on that hall. The distinction between contact precautions and enhanced barrier precautions, she explained, is straightforward: contact precautions mean PPE goes on before you enter, every single time, including for tray delivery. Enhanced barrier precautions, used for residents with other clinical needs but no GI symptoms, allow staff to put on PPE once they're already inside the room.
The CNAs knew the difference. They said so. The supervisors knew the difference. They said so. The policy was written down.
On the morning of September 3, with five residents sick and the unit locked down, two CNAs moved through isolation rooms and then into the rooms of healthy residents, carrying food, without the protective equipment everyone agreed they were supposed to be wearing.
The surveyor cited the facility for failing to maintain an infection prevention and control program sufficient to prevent the development and transmission of communicable diseases. The violation was cited as having the potential to affect all 14 residents on the unit.
Thirteen of those residents were in their rooms that morning. One had left for dialysis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rib Lake Health Services from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
RIB LAKE HEALTH SERVICES in RIB LAKE, WI was cited for violations during a health inspection on September 3, 2025.
A federal surveyor watched the whole thing happen at 8:05 a.m.
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.