The facility admitted the woman on November 3rd at 2:30 PM following a hospitalization for sepsis related to the severe tissue infection. Federal regulations require nursing homes to develop care plans within 48 hours of admission.
Three weeks later, inspectors discovered no wound care plan existed.
The resident had endured multiple surgical debridements during her hospital stay to remove dead tissue from a wound measuring 20 by 11 by 2 centimeters. She suffered a stroke while hospitalized, required mechanical ventilation, and scored 12 out of 15 on a cognitive assessment, indicating moderately impaired mental function.
Her hospital discharge summary included specific wound care instructions. Doctors ordered a wound vacuum device to be applied the day of admission. They prescribed vancomycin irrigation to be applied twice daily to the affected area until the wound vacuum was in place. She was to continue Augmentin antibiotics for six more days.
The facility received these detailed medical orders.
Yet when inspectors reviewed the resident's care plan on November 24th, they found entries for a Foley catheter and advance directives. No wound care plan appeared anywhere in her records.
Licensed Practical Nurse B confirmed to inspectors that staff had never developed a baseline wound care plan for the resident.
The woman's condition represented one of the most serious types of soft tissue infections. Necrotizing fasciitis destroys tissue rapidly and can be fatal without aggressive treatment. Fournier's gangrene specifically affects the external genitalia and surrounding area, requiring intensive wound management to prevent further tissue death.
Hospital doctors had placed a Foley catheter specifically to keep the wound area clean during healing. The discharge instructions emphasized the urgency of beginning wound vacuum therapy immediately upon arrival at the nursing facility.
Federal inspectors found the facility violated regulations requiring immediate care planning for residents' most pressing medical needs. The regulation exists because the first 48 hours after admission represent a critical window when new residents are most vulnerable to complications or deterioration.
The facility's physician had written orders for the resident's antibiotics and pain medication. Staff documented her catheter care and advance directive status in her care plan. But the most serious aspect of her condition, the extensive groin wound requiring specialized treatment, received no formal care planning.
The resident had been hospitalized for weeks receiving round-the-clock medical attention for her life-threatening infection. Multiple surgeries had been required to remove dead tissue. Infectious disease specialists had carefully calibrated her antibiotic regimen.
Upon discharge to the nursing facility, she needed continuation of this intensive wound management to prevent reinfection or further tissue death.
The inspection occurred three weeks after her admission. During that entire period, no baseline wound care plan guided staff in managing her complex medical needs.
The facility's failure affected what inspectors classified as "few" residents, suggesting similar planning deficiencies for other newly admitted patients with urgent medical conditions.
Inspectors rated the violation as causing minimal harm or potential for actual harm. However, the resident's condition, involving aggressive tissue infection in a cognitively impaired stroke survivor, left little margin for care planning errors.
The woman remained at Careview Health and Rehab during the inspection, her wound care managed without the systematic planning framework that federal regulations require for all nursing home residents within their first two days of admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careview Health and Rehab of Minocqua from 2025-11-24 including all violations, facility responses, and corrective action plans.