Suring Health and Rehab: Immediate Jeopardy Pain Failure - WI
The inspection, triggered by a complaint and completed September 15, 2025, resulted in a finding of immediate jeopardy, the most serious classification federal regulators assign, reserved for situations where a facility's failures have caused or are likely to cause serious injury or death.
The nurse at the center of the finding is identified in the inspection report only as RN-D. She was caring for the resident, identified as R1, from 6:00 PM until the point R1 was transferred to the emergency room. What she did not do during that window is the substance of the citation.
The facility's Director of Nursing, identified as DON-B, spelled out what should have happened. Orders the physician had provided, including for increased acetaminophen, diclofenac cream, and to wean R1 from supplemental oxygen, should have been transcribed into R1's medical record within two hours of receipt. RN-D should have completed a full assessment, including vital signs and a range of motion assessment. She should have updated the physician with the results of that assessment. She should have administered the as-needed medications available to her, including diclofenac gel, acetaminophen, and tramadol. She should have documented, in real time, every action taken to address R1's pain.
None of that happened.
DON-B told inspectors that when a resident is in pain, staff are expected to complete a pain assessment, provide non-pharmacological interventions, and administer and document medications. DON-B confirmed she spoke directly with RN-D about these steps. RN-D did not complete them.
DON-B also told inspectors that staff should physically check on a resident after giving pain medication to confirm it is working, and that oxygen use, when occurring, needs to be recorded in the medical record. There is no indication in the inspection report that either of those things happened for R1.
The inspection report states directly: the failure to recognize and act upon a change in condition in a timely manner led to serious harm for R1.
What that harm looked like in specific clinical terms, the inspection report does not describe. What it does say is that R1 was still hospitalized on the date inspectors completed their work, weeks after the events that triggered the complaint.
Immediate jeopardy was removed on September 5, 2025, after the facility submitted and began implementing a corrective action plan. But inspectors did not close the citation entirely. They downgraded it to a scope and severity level D, meaning deficient practice that carries potential for more than minimal harm in isolated cases, because the facility was still in the process of making the required fixes.
Those fixes, as described to inspectors, included conducting head-to-toe assessments on every resident then living in the facility. The facility also said it implemented a standardized electronic evaluation tool for identifying and responding to changes in condition, and began reviewing in-house residents during daily meetings that bring together staff from multiple disciplines to check on documentation, assessments, vital signs, and whether physicians had been notified of any changes. Staff received education on the facility's own policies covering pain management, change of condition identification, notification of providers, and how to transcribe and document orders. The facility said it launched audits and began reviewing progress notes to monitor how staff were responding to changes in condition going forward.
One of the more telling details in DON-B's account to inspectors is the paper system the facility said it was putting in place. Staff discussing a concern would fill out a triple carbon copy form, with copies going to the nurse, to DON-B, and to the nursing home administrator, identified as NHA-A. The purpose, as DON-B described it, was to make sure concerns actually get followed up on.
That a facility needs a three-copy paper trail to ensure a nurse's concern reaches the director of nursing and the administrator suggests something about how information had been moving, or not moving, before R1's transfer to the emergency room.
The inspection report does not describe whether anyone at the facility knew R1 was deteriorating before the transfer and failed to escalate, or whether RN-D simply did not recognize what she was seeing. It does not describe what R1's pain looked like during those hours, whether R1 was verbal, whether R1 asked for help, or whether anyone else on the floor that night observed what was happening. The report identifies only what the nurse responsible for R1's care failed to do, and what the director of nursing said should have been done instead.
Suring Health and Rehab Center is a small facility in Oconto County in rural northeastern Wisconsin. The nearest hospital is not in Suring itself, which means an emergency room transfer from this facility is not a quick or minor undertaking. The inspection report does not specify where R1 was taken or what treatment R1 received after arrival.
What the record shows is a physician who had already issued orders to address R1's condition, a nurse who received those orders and did not transcribe them, did not carry them out, and did not document that she had tried anything at all, and a resident who left the building by ambulance and had not returned by the time inspectors finished their work.
DON-B's conversation with RN-D, the one in which DON-B laid out every step the nurse should have taken, happened after R1 was already gone.
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.
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 22, 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 nurse at the center of the finding is identified in the inspection report only as RN-D.
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.