Beaver Dam Health Care Center: Missed Wound Care, Vitals - WI
The resident, identified in inspection records as R2, was admitted to Beaver Dam Health Care Center with sepsis. A physician ordered a powerful antibiotic, Daptomycin, to be administered once daily by IV for 33 days, starting October 9, 2025. The care plan flagged an active infection, endocarditis caused by Enterococcus bacteria, serious enough to require intravenous treatment.
Over the course of that antibiotic regimen, staff recorded vital signs on exactly six days: October 9, 10, 11, 12, 22, and 24. Then nothing in the record after that until November, when a skilled nursing assessment appeared on November 11 and 12, just before inspectors arrived on November 13.
That left stretches of more than a week, and then nearly three weeks, with no documented blood pressure, pulse, or temperature for a resident on daily IV antibiotics for a bloodstream infection.
The Director of Nursing, identified in the report as DON B, told the surveyor directly that IV antibiotics count as skilled services, and that a resident receiving them should have daily vital signs and a daily assessment. He said R2 should have had both. He confirmed R2 did not.
A second resident, R3, was receiving wound care under a physician's order. The treatment administration record showed blanks, meaning treatments were not completed. Nobody notified the physician, the wound care team, or a nurse practitioner that the care had been skipped, whether because the resident had refused, had been away from the facility, or for any other reason.
The Director of Nursing said, when asked, that yes, he expected physician orders to be followed. He said he would expect a physician to be notified when wound care wasn't completed. When the surveyor told him about the blanks on R3's record, he said he would look for documentation. He came back and said he could not find any.
The nurse practitioner, NP D, said the same thing independently. She told the surveyor she would expect a medical provider, whether the wound care team, a physician, or an NP, to be notified any time wound care wasn't completed, whatever the reason.
Nobody had been.
The facility's own documentation policies, in place since at least 2017, require that treatments be recorded with the date and time they were performed, how the resident tolerated the procedure, and any assessment findings. For residents receiving skilled services, the policy calls for vital signs at least daily.
The gap between what the policies said and what the records showed was the same gap DON B acknowledged out loud to the surveyor. He did not dispute it.
Federal inspectors tagged both findings under F0684, which covers the requirement that residents receive care in accordance with professional standards of practice and their physician's orders. The level of harm was cited as minimal harm or potential for actual harm.
What the inspection record does not contain is any account of what R2 experienced during those weeks without documented monitoring. Endocarditis is an infection of the heart's inner lining. Daptomycin, the antibiotic ordered for R2, carries known risks including muscle damage and lung complications. Catching those problems early depends on monitoring. The vitals that would have shown a fever climbing, a pulse going irregular, or blood pressure dropping were not being taken, or not being recorded, or both.
The record is silent on which.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beaver Dam Health Care Center from 2025-11-13 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 22, 2026 · Our methodology
BEAVER DAM HEALTH CARE CENTER in BEAVER DAM, WI was cited for violations during a health inspection on November 13, 2025.
The resident, identified in inspection records as R2, was admitted to Beaver Dam Health Care Center with sepsis.
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.