Careview Health And Rehab Of Minocqua

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

deep wound are all covered with stool.At this point decision has been made to send the patient back to a local emergency room for application of wound VAC.Plan: patient will be sent to local emergency room once again the patient will need a wound VAC application after wound is cleaned and free from feces. The patient would really need wound VAC should be applied prior to discharge to skilled nursing facility and if there is a need to switch the wound VAC the nursing facility could switch it and ensure there is no contamination of stool to the right wound because that is the primary goal. Also it would allow healing and that the patient could have grafting skin graft down the road. On 11/24/25 at 12:04 PM, Surveyor interviewed Registered Nurse (RN) F. RN F reported she was present when Resident R1 admitted but was not Resident R1's admitting nurse. The admitting nurse was from an agency. RN F stated Resident R1's admitting orders included wound care orders, but again was not sure of the orders as she did not admit Resident R1. RN F stated, We didn't know she (Resident R1) was supposed to have vancomycin solution. RN F reported on 11/05/25, she worked on the hall Resident R1 resided on and noted Resident R1 had a wound without wound care orders. RN F stated she called NP D for an order to complete a wet-to-dry dressing change. RN F reported no concerns related to Resident R1 having pain. On 11/24/25 at 12:15 PM, Surveyor interviewed MD C. MD C was able to recall the situation with Resident R1, stating Resident R1's wound appeared as if it had been packed with stool. Surveyor asked MD C about Resident R1's orders for vancomycin solution twice daily and a wound VAC. MD C stated, I don't really know what to say. Whatever is not written was not done. MD C confirmed the wound VAC would help keep the wound from being contaminated with stool as, The wound was in a bad area. MD C was not sure why wound VAC was not delivered to the facility, or why the vancomycin solution was not administered as ordered, as 11/06/25 was his first visit with Resident R1.

MD C stated moving forward the facility needs to ensure a resident arrives with an already placed wound VAC, or that a wound VAC arrives to the facility prior to a resident's admission. On 11/24/25 at 12:53 PM, Surveyor interviewed Licensed Practical Nurse (LPN) B who reported on 11/05/25 staff found documentation in Resident R1's room indicating Resident R1 was to have a wound VAC, and this was the first date staff were aware Resident R1 was to have a wound VAC. LPN B stated she ordered the wound VAC, and it was delivered on 11/05/25 at 8:18 PM. LPN B stated staff went to place wound VAC the morning of 11/06/25, and that is when it was noted Resident R1 had stool in her wound, and was sent to the emergency room. Surveyor noted to LPN B, Resident R1's hospital discharge orders, received on 11/03/25 and scanned into Resident R1's record on 11/04/25, included instructions for both the vancomycin solution and wound VAC. Surveyor noted to DON B the order for vancomycin solution was not documented in Resident R1's physician orders, TAR, or record until 11/05/25, when RN F updated NP D that the facility did not have vancomycin solution, and a wet-to-dry dressing was ordered until vancomycin arrived. Surveyor was unable to find evidence the facility ordered vancomycin solution at all. Surveyor noted to LPN B, Resident R1's record showed Resident R1 did not receive any wound care on 11/03/25-PM shift, 11/04/25-AM and PM shift, and 11/05/25-PM shift, prior to being sent the emergency room on [DATE REDACTED]. LPN B stated she believed Resident R1 had received appropriate care between 11/03/25-11/06/25, and she would attempt to obtain additional evidence to support this. No additional documentation was provided. On 11/24/25, Surveyor attempted to interview Resident R1's admitting nurse, without success.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Careview Health and Rehab of Minocqua

9969 Old Hwy 70 Rd Minocqua, WI 54548

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not ensure a baseline care plan was developed and implemented for each resident (R) within 48 hours of admission for 1 of 3 residents reviewed (Resident R1).Resident R1 was admitted with a non-pressure related wound and wound care orders; a baseline care plan for wound care was not developed. Resident R1 was admitted to the facility on [DATE REDACTED] at approximately 2:30 PM, after a hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene (gangrene affecting the external genitalia or perineum), of the right groin. Resident R1 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition.Resident R1 was hospitalized from [DATE REDACTED]-[DATE REDACTED]. Resident R1 suffered a stroke during her hospitalization, was intubated, and required mechanical ventilation, Resident R1 was successfully extubated prior to her discharge from the hospital. During Resident R1's hospitalization, she required multiple debridements of right groin wound, and extensive antibiotic therapy. A Foley catheter was placed to keep

the area clean. Last noted wound measurements were on 10/31/25, 20 x 11 x 2 cm. Upon Resident R1's hospital discharge, she was discharged from infectious disease (ID) with recommendations for initiation of a wound VAC.On 11/03/25, Resident R1's hospital discharge summary included the following as it relates to her wound:-Augmentin for six more days on discharge, no need to follow with ID.- She is supposed to get a wound Vac today in SNF.-Vancomycin 1% irrigation, apply twice daily to affected area.-Instructions: BID (twice daily) vancomycin to wound kerlex until wound vac on. Resident R1's facility physician orders included:-11/03/25, Augmentin 500-125 mg two time a day for skin and soft tissue infection.-Acetaminophen, 500 mg. Give two tablets, three times per day. Resident R1's care plan included:-11/04/25, Foley catheter-11/05/25, Advanced Directives(Note, Resident R1's care plan did not include wound care). On 11/24/25 at 3:20 PM, Surveyor interviewed Licensed Practical Nurse (LPN) B. LPN B confirmed a baseline care plan for wound care was not developed for Resident R1.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Careview Health and Rehab of Minocqua

9969 Old Hwy 70 Rd Minocqua, WI 54548

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

noted to LPN B, Resident R1's hospital discharge orders, received on 11/03/25 and scanned into Resident R1's record on 11/04/25, included instructions for both the vancomycin solution and wound VAC.Surveyor noted to LPN B

the order for vancomycin solution was not documented in Resident R1's physician orders, TAR, or record until 11/05/25, when RN F updated NP D that the facility did not have vancomycin solution, and a wet-to-dry dressing was ordered until vancomycin arrived. Surveyor was unable to find evidence the facility ordered vancomycin solution at all. Surveyor noted to LPN B, Resident R1's record showed Resident R1 did not receive wound care on 11/03/25-PM shift, 11/04/25-AM and PM shift, and 11/05/25-PM shift, prior to being sent the emergency room on [DATE REDACTED]. LPN B stated she believed Resident R1 had received appropriate care between 11/03/25-11/06/25, and she would attempt to obtain additional evidence to support this. No additional documentation was provided to Surveyor. On 11/24/25, Surveyor attempted to interview Resident R1's admitting nurse, without success.Resident R1 did not return to the facility following the hospitalization on 11/06/25.

Event ID:

Facility ID:

If continuation sheet