Suring Health and Rehab: Immediate Jeopardy Pain Failure - WI
Federal inspectors declared immediate jeopardy at Suring Health and Rehab Center following a September 2025 complaint inspection, concluding that the facility's failure to recognize and act on a change in condition caused serious harm to the resident, who was still hospitalized when inspectors completed their review.
The inspection report, based on interviews with the resident, the attending physician, and the facility's director of nursing, describes a cascade of missed steps across a single day in late August — missed assessments, orders that sat untranscribed, pain medications that were available but apparently never given, and a nurse who, by the director of nursing's own account, did not follow the basic steps required to care for someone in crisis.
The resident, identified only as R1, recalled that the day began with pain that was different from what they had experienced before. Something changed in the shower. The resident told inspectors the pain was unlike anything they had felt and that it was hard to breathe. By evening, they were rating their pain at a ten out of ten.
The attending physician, interviewed by inspectors on September 3, said it plainly: when a resident complains of a different type of pain in the shower, staff should have called him. If anything is off, if a resident isn't acting like themselves, staff should call him. If a resident has increased shortness of breath despite oxygen, doesn't get better with oxygen, or needs more oxygen, staff should call him. None of those calls came.
What the resident remembered of that day was fragmented. They told inspectors they were fuzzy on the details. They weren't sure whether they had received tramadol or any pain medication at all. A nurse entered the room close to seven in the evening, and the resident thought she was going to give them Tylenol. They weren't sure if they got it. They told her they needed something stronger. They didn't know whether anything stronger ever came.
What the resident did remember clearly was telling a nursing assistant they needed to see a nurse. They remembered that their pain was at a ten. They remembered that staff brought ice and heat. They remembered that sitting up was easier than lying down, and that they had started using oxygen as the evening wore on. They remembered that nobody sent them to the hospital until they said, themselves, that they needed to go.
Earlier that same day, at 9:35 in the morning, a nurse practitioner had called in new orders: increased acetaminophen, diclofenac cream, and instructions to begin weaning the resident from oxygen. The director of nursing told inspectors those orders should have been transcribed into the resident's medical record within two hours of receipt. They were not transcribed in time. The nurse caring for the resident that morning, the director said, should have completed a full assessment, including vital signs and a range of motion check, and should have updated the physician with the results. That did not happen either.
The director of nursing was direct about what should have followed. Staff should have administered the as-needed diclofenac gel. They should have administered acetaminophen. They should have administered tramadol if needed. They should have documented what they gave and whether it worked, in real time, as they gave it. If a resident is in pain, the director said, staff complete a pain assessment, offer non-pharmacological options, and give and document the medications. That sequence did not happen.
The nurse who covered the evening shift, from six in the evening until the resident was finally transferred to the emergency room, was later interviewed by the director of nursing. The director told inspectors she had walked the nurse through the steps that should have been taken. The nurse, the director confirmed, had not completed those steps. She also told inspectors that staff needed to be reminded to physically check on a resident after giving pain medication to make sure it is working, and that oxygen use needed to be documented in the medical record.
The resident was still in the hospital when inspectors finished their review.
Inspectors found the immediate jeopardy removed on September 5, two days after the inspection began, but the underlying deficiency remained. The facility had begun a series of corrective steps: head-to-toe assessments for all current residents, a new electronic evaluation tool for changes in condition, daily team meetings to review residents and catch documentation gaps, staff education on notification procedures and pain management, and audits of progress notes to check whether change-of-condition responses were being completed.
The facility also told inspectors it was implementing a triple carbon copy system so that when a staff member has a concern, they can write it down and hand copies to the nurse, the director of nursing, and the administrator, to make sure someone follows up.
A paper system designed to ensure that a nurse tells someone a resident is in pain.
What the inspection report captures, across its pages, is not a single reckless act. It is a series of ordinary failures, each one the kind of thing that might seem small in isolation: an order not transcribed quickly enough, an assessment not completed, a medication not given, a physician not called, a nurse who went through a shift without doing what her own director said she should have done. Each one small. Together, they left a person lying in a bed for hours, breathing with difficulty, rating their pain at the highest number on the scale, waiting for someone to decide it was serious enough to act.
The resident told inspectors that staff knew they were hurting. Staff knew they were having trouble breathing. At around nine in the evening, the resident said, they couldn't take it any longer.
They asked to go to the emergency room. Then they went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Suring Health and Rehab Center from 2025-09-15 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 29, 2026 · Our methodology
Suring Health and Rehab Center in Suring, WI was cited for immediate jeopardy violations during a health inspection on September 15, 2025.
The resident, identified only as R1, recalled that the day began with pain that was different from what they had experienced before.
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.