TOMAH, WI - Federal health inspectors issued an immediate jeopardy citation to Tomah Nursing and Rehab following a complaint investigation completed on December 22, 2025, after determining the facility failed to keep its environment free from accident hazards and did not provide adequate resident supervision. The facility was given a deadline to correct the deficiency and reported compliance as of January 9, 2026.
Immediate Jeopardy: The Most Serious Federal Deficiency
The citation issued to Tomah Nursing and Rehab carries a Scope/Severity Level J rating — classified as an isolated incident that poses immediate jeopardy to resident health or safety. In the federal nursing home inspection framework, immediate jeopardy represents the highest and most serious category of deficiency that regulators can assign.
The Centers for Medicare & Medicaid Services (CMS) defines immediate jeopardy as a situation in which a facility's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Unlike lower-level deficiencies that may involve potential for minimal harm or no actual harm, an immediate jeopardy finding signals that inspectors identified conditions so dangerous that they required urgent action.
Under the federal enforcement system, nursing homes found to have immediate jeopardy conditions face an accelerated enforcement timeline. CMS may impose civil monetary penalties of up to $25,985 per day for each day the immediate jeopardy persists, and facilities that fail to correct the deficiency within the required timeframe can face additional sanctions, including denial of payment for new admissions or even termination from the Medicare and Medicaid programs.
The deficiency was classified under regulatory tag F0689, which falls within the broader category of Quality of Life and Care Deficiencies. This tag specifically addresses a facility's obligation to ensure that residents live in an environment that is free from recognized accident hazards and that staff provide a level of supervision adequate to prevent foreseeable accidents.
What F0689 Requires of Nursing Facilities
Federal regulation F0689 is one of the most frequently cited deficiency tags across the nation's approximately 15,000 Medicare- and Medicaid-certified nursing homes. The regulation requires facilities to take a proactive approach to identifying environmental risks and to implement individualized supervision plans based on each resident's assessed needs.
Compliance with this standard means that a nursing home must conduct thorough assessments of each resident's physical and cognitive abilities, identify risk factors for falls, burns, elopement, and other accidents, and then develop care plans that include specific interventions to reduce those risks. These interventions may include measures such as bed alarms, non-slip flooring, adequate lighting, secured exit doors, wheelchair locks, and — critically — appropriate staffing levels to ensure that residents who need hands-on assistance or close monitoring actually receive it.
When a facility is found deficient under F0689, it typically means that one or more of these safeguards was either absent, inadequately implemented, or not followed by staff. The fact that this particular citation reached the immediate jeopardy threshold indicates that the gap between what was required and what was provided was significant enough to place at least one resident in imminent danger of serious harm.
The Complaint Investigation Process
This citation resulted from a complaint investigation rather than a routine annual survey. Federal and state survey agencies maintain complaint hotlines that allow residents, family members, staff, and others to report concerns about care quality or safety in nursing homes. When a complaint is received, the survey agency evaluates it and determines whether an on-site investigation is warranted and how quickly the investigation must begin.
Complaints alleging immediate jeopardy or actual harm must be investigated within two to ten business days, depending on the severity of the allegations. Standard complaints that do not allege immediate jeopardy are typically investigated within approximately 45 days or during the next scheduled survey, whichever comes first.
The fact that inspectors conducted a targeted complaint investigation at Tomah Nursing and Rehab suggests that someone — whether a resident, a family member, an employee, or another concerned party — reported conditions serious enough to prompt regulatory action. Complaint investigations are typically more focused than annual surveys, zeroing in on the specific allegations rather than reviewing all aspects of facility operations.
During such investigations, federal and state inspectors interview residents and staff, review medical records and incident reports, observe care delivery, and evaluate the physical environment. Their findings are documented in a Statement of Deficiencies, which becomes part of the facility's public record and is accessible through the CMS Care Compare website.
Medical Implications of Accident Hazards and Inadequate Supervision
Accident hazards in nursing homes pose particularly serious risks because the population served is inherently vulnerable. The typical nursing home resident is elderly, may have multiple chronic conditions, often takes medications that affect balance or alertness, and may have cognitive impairments such as dementia that limit the ability to recognize or avoid dangers.
Falls are the most common accident in nursing homes and represent a leading cause of injury-related death among older adults. Approximately 50 to 75 percent of nursing home residents experience a fall each year — roughly twice the rate seen among community-dwelling older adults. For residents who fall, the consequences can be severe: hip fractures, which carry a one-year mortality rate of approximately 20 to 30 percent in elderly patients; traumatic brain injuries, which can cause permanent cognitive decline; and soft tissue injuries that may lead to immobility, pressure ulcers, and a cascading decline in overall health.
Beyond falls, inadequate supervision can expose residents to a range of other hazards. Residents with dementia or other cognitive impairments may wander into unsafe areas, leave the facility without staff knowledge (a phenomenon known as elopement), access cleaning chemicals or medical supplies, or encounter environmental hazards such as wet floors, malfunctioning equipment, or extreme temperatures.
The medical reality is that many of these accidents are preventable when facilities implement and follow evidence-based protocols. Systematic fall risk assessments using validated tools, targeted exercise programs to improve balance and strength, medication reviews to minimize fall-risk-increasing drugs, and environmental modifications have all been demonstrated to reduce accident rates in long-term care settings.
Correction Timeline and Facility Response
According to the inspection record, Tomah Nursing and Rehab reported correcting the identified deficiency as of January 9, 2026 — approximately 18 days after the inspection date. The correction status is listed as "Deficient, Provider has date of correction," meaning the facility acknowledged the deficiency and submitted a plan of correction to the state survey agency.
A plan of correction is a written document in which the facility describes what steps it has taken or will take to correct the deficiency, how it will ensure the deficiency does not recur, and how it will monitor ongoing compliance. While submission of a plan of correction does not necessarily mean the problem has been fully resolved, the state survey agency may conduct a revisit survey to verify that the corrective actions have been effectively implemented.
For immediate jeopardy situations, the enforcement timeline is compressed. Facilities are typically required to remove the immediate jeopardy condition within 23 calendar days from the last day of the survey. If the immediate jeopardy is not removed within this timeframe, CMS is required to impose a remedy, which may include termination of the facility's provider agreement.
The 18-day correction timeline reported by Tomah Nursing and Rehab falls within this enforcement window, suggesting the facility took steps to address the conditions that prompted the citation before the mandatory deadline.
Industry Context and National Trends
Tomah Nursing and Rehab's immediate jeopardy citation fits within broader national patterns in nursing home oversight. According to CMS data, deficiencies related to accident hazards and supervision (F0689 and its predecessor tags) consistently rank among the top ten most frequently cited deficiencies during nursing home inspections nationwide.
However, while the tag is commonly cited, the vast majority of F0689 citations are at lower severity levels — typically at the "no actual harm with potential for more than minimal harm" threshold. An immediate jeopardy finding under F0689 is relatively uncommon and signals conditions that go well beyond typical compliance gaps.
Nationally, nursing homes have faced increased scrutiny in recent years over staffing levels, infection control, and resident safety. The federal government finalized a minimum staffing rule that requires facilities to maintain specific nurse-to-resident ratios. Adequate staffing is directly linked to a facility's ability to provide the supervision necessary to prevent accidents — the very standard at issue in the Tomah Nursing and Rehab citation.
What Families Should Know
Family members and prospective residents evaluating nursing home options can access a facility's complete inspection history, including deficiency citations, complaint investigations, and staffing data, through the CMS Care Compare website. This publicly available database allows consumers to compare facilities based on their inspection results, quality measures, and staffing levels.
For Tomah Nursing and Rehab, the immediate jeopardy citation will appear on its public record and may affect its overall star rating on the CMS website. Families with loved ones currently residing at the facility may wish to request a copy of the full Statement of Deficiencies and the facility's plan of correction to understand the specific circumstances that led to the citation and what changes have been implemented.
Residents and family members who have concerns about safety or care quality at any nursing home can file a complaint with the Wisconsin Department of Health Services, which oversees nursing home inspections in the state, or contact the Long-Term Care Ombudsman Program, which advocates on behalf of residents in long-term care facilities.
For the full inspection details and the facility's complete compliance history, readers can visit the CMS Care Compare database or the NursingHomeNews.org facility page for Tomah Nursing and Rehab.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tomah Nursing and Rehab from 2025-12-22 including all violations, facility responses, and corrective action plans.
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