Rib Lake Health Services: Staff Spread Infection Risk - WI
The infection control violations at Rib Lake Health Services affected all 14 residents living on the south unit, where five residents were on contact precautions due to gastrointestinal symptoms that prompted a unit lockdown.
On the morning of September 3, state surveyors watched certified nursing assistants H and G deliver breakfast trays starting from the nurses' station and working their way down the hallway. CNA H entered the rooms of residents 5 and 6 without the required gown and gloves, even though both residents were on contact precautions for gastrointestinal illness.
After leaving those contaminated rooms, CNA H proceeded directly to resident 11's room to deliver food. Resident 11 was not on contact precautions.
CNA G followed the same pattern, entering the rooms of residents 7 and 9 without protective equipment, then delivering food to resident 12, who was also not on isolation precautions.
The facility's own policy requires healthcare personnel to wear gowns and gloves "for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment" when residents are on contact precautions.
When interviewed later that morning, Director of Nursing B confirmed that staff must follow contact precautions "whenever they go in their room, even passing trays." She explained that protective equipment should be put on outside the room for contact precautions, distinguishing this from enhanced barrier precautions where staff can put on gear after entering.
Assistant Director of Nursing I described the unit lockdown, explaining that five residents had gastrointestinal symptoms requiring contact precautions. The affected residents were in rooms throughout the hallway.
"Contact precautions mean you put on your PPE prior to entering," she told inspectors. "PPE should be put on prior to passing trays when resident is on contact precautions."
CNA H acknowledged the violation when questioned. "Contact precautions are used for anyone that was sick. It means you put on your PPE before entering the room," she said. When asked if this included delivering water or food trays, she responded: "That is including when passing trays; I missed one today."
CNA G demonstrated similar understanding of the requirements but admitted failing to follow them. "Contact precautions is every time you go into a room," she explained, correctly identifying which residents needed the precautions.
When asked whether she wore protective gear while delivering breakfast, she said: "Probably not, I didn't think to do it until I went into R7's room."
The violations created a direct pathway for disease transmission. Staff members who entered contaminated rooms without protective equipment then handled food and entered the rooms of healthy residents without changing gloves or washing hands between contacts.
Fourteen residents lived on the affected hallway, with five requiring contact precautions due to active gastrointestinal illness. One resident was off the unit for dialysis during the observed breakfast service, leaving thirteen residents potentially exposed to cross-contamination.
The facility policy, updated in September 2024, specifically addresses transmission-based precautions intended to prevent the spread of pathogens through direct or indirect contact with residents or their environment.
State inspectors found the infection control program failures had "minimal harm or potential for actual harm" but noted the violations affected the entire residential population on the unit.
The inspection occurred during a complaint investigation, suggesting concerns about infection control practices prompted the state review. The facility's south unit remained on lockdown during the inspection due to the ongoing gastrointestinal outbreak among residents.
Both nursing assistants demonstrated knowledge of proper infection control procedures during interviews but failed to implement them during actual patient care, creating unnecessary exposure risks for vulnerable elderly residents.
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.
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: June 20, 2026 · Our methodology
RIB LAKE HEALTH SERVICES in RIB LAKE, WI was cited for violations during a health inspection on September 3, 2025.
After leaving those contaminated rooms, CNA H proceeded directly to resident 11's room to deliver food.
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.