Rivers Edge Nursing And Rehab
Rivers Edge Nursing and Rehab in Muscoda, WI — inspection on April 21, 2025.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
cognitively intact.
door entrance of R13's room.
Surveyor observed several items on the floor which include: a Kleenex
another Kleenex box and an empty foam wound dressing box on the floor, a pink piece of paper on the floor, and an opened plastic gallon water jug by the door. R13 stated he would prefer his room to be cleaner.
On 4/3/25 around 11:10 AM, Surveyor asked NHA A to walk to R13's room with Surveyor and asked NHA A if the floor and room were clean. NHA A indicated the items on the floor shouldn't be there, room wasn't clean and homelike.
On 4/3/35 around 11:35 AM, Surveyor asked Housekeeper N to walk to R13's room with Surveyor and asked Housekeeper N if the room was clean.
Housekeeper N indicated the items on the floor should have been picked up and room wasn't clean.
Example 8 On 4/3/25 at 8:30 AM, Resident Representative Q indicated R3's wheelchair is often observed unclean with food crumbs and dried dripping marks on it.
Resident Representative Q indicated she does not think staff have a system in place for upkeeping the cleanliness of the wheelchairs.
Example 9 R3 admitted to the facility on [DATE] with diagnoses including Parkinson's Disease with Dyskinesia, Fibromyalgia, spinal stenosis, bipolar disorder, abnormal posture, age-related osteoporosis .Her most recent Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 2/21/25 indicates she is dependent on staff assistance to meet her activities of daily living (ADL) needs.
On 4/3/25 at 10:43 AM, Housekeeper L indicated she is not sure who is responsible for cleaning wheelchairs, but she knows it is not the housekeeping department.
On 4/3/25 at 2:40 PM CNA/MT E (Certified Nursing Assistant/Medication Technician) indicated he does not think there is a set schedule for wheelchair cleaning, and he is not sure who is responsible for cleaning wheelchairs.
On 4/3/25 at 2:43 PM CNA F indicated she is not sure how often wheelchairs get cleaned and she is unsure who is responsible for cleaning wheelchairs.
On 4/3/25 at 2:46 PM CNA G indicated she is not sure how often wheelchairs get cleaned. CNA G indicated a long time ago there was a book with a schedule for wheelchair cleaning, but she does not know what happened to the book.
On 4/7/25 at 4:52 PM DON B (Director of Nursing) indicated anyone can wash a wheelchair and they should be being washed on the same day as the residents' scheduled bath day.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
anyone else or report it to the supervisor until recently.
R10's missing gray scrub top. HKL P indicated she first heard about R10's missing top from LA O last
search, if they can't find it, the facility replaces it.
Surveyor asked how long they wait before telling someone else about the missing item and HKL P stated about 2 weeks. HKL P stated they will let medical records know after a couple weeks so the facility can replace the item.
Of note, neither staff stated they would document the incident, file a grievance or report the missing item to the Grievance Official.
On 4/7/25 at 2:40 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what the expectation is for staff if a resident says they're missing a clothing item. NHA A indicated he would expect staff to tell the Social Worker to report it, search for the item, look throughout the building, ask staff to help look for the item, fill out a grievance, and the facility will replace it if not found.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
jeopardy to resident health or for evaluation of leg wound.
Guardian feels patient developed wound that was not being attended to at safety care facility and when this was not improving wanted him to be seen and evaluated in the ED for further workup and management.
Lab: ESR and CRP (ESR - erythrocyte sedimentation rate- lab
inflammation in body) elevated indicating increased inflammation. [NAME] blood cell counts normal (used to check for infection).
Right tibia/fibula (lower leg) x-ray: no evidence to suggest osteomyelitis (infection of bone). No subcutaneous gas on x-ray (if gas present can indicate infection). ED Course: I am concerned patient has developed cellulitis around this wound and he is given Ceftriaxone (antibiotic) here in the ED.
Lab work overall reassuring. admission for treatment of cellulitis and wound.
Impression: Cellulitis of wound grade 2 decubitus ulcer. A wound culture was obtained and R18's wound culture grew out MRSA (Methicillin Resistant Staph Aureus).
X-ray results 4/15/25 - Right tibia/fibula (lower leg) x-ray: no evidence to suggest osteomyelitis.
History and Physical dated 4/15/25: Leg ulcer (acute).
Plan: Right leg ulcerations: Cellulitis.
Chronic appearing ulcerations, history of venous insufficiency, however, appearance more arterial.
Erythema (red), plus warmth around ulcerations, received Rocephin in ED will continue, afebrile (no fever) and normal white blood cell count (no showing acute systemic infection).
Arterial ultrasound normal, will benefit from vascular surgeon evaluation.
Physician note dated 4/1[TRUNCATED]
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
includes .coccyx (tailbone) reddened and scrotal area.
Will have wound care readdress areas.
building .en route to [Town name].
*4/9/25 2:21 PM .returned from [Town name] area Hospital .
R15's Wound Visit Reports state, in part: *3/24/25 .Right heel pressure ulcer 0.5x0.5x0.1 (length by width by depth in centimeters) . unstageable *3/31/25 .No measurements obtained today for wounds.
Patient's wound evaluation was abbreviated due to acute respiratory distress.decision was made to transport the patient to [Emergency department] for further eval *4/7/25 .No measurements obtained today for wounds.
Patient's wound evaluation was abbreviated due to respiratory distress. *4/14/25 .Right heel pressure ulcer 4.5x11.2x0.1 unstageable Important to note: there is no documentation of wound assessments for 4/4/25 and/or 4/9/25 when R15 returned from the hospital.
On 4/17/25 at 8:13 AM, Surveyor interviewed RN BB (Registered Nurse) and asked how often wounds are assessed. RN BB stated weekly by the charge nurse.
Surveyor asked about skin protocol when a resident returns from the hospital. RN BB stated there is a skin assessment and wound evaluation completed.
On 4/17/25 at 8:25 AM, Surveyor interviewed IDON X (Interim Director of Nursing) and asked how often wounds are to be assessed. IDON X stated that the assessments occur weekly with wound consultant and facility nurse.
Surveyor asked what happens if a resident is not available/in house when the wound consultant rounds. IDON X stated the care continues as ordered and the consultant will assess the following week.
Surveyor asked about skin protocol when a resident returns from the hospital. IDON X stated a skin assessment is completed when the resident returns.
Surveyor asked if there was a skin assessment on 4/4/25 and/or 4/9/25 when R15 returned from the hospital. IDON X reviewed the chart and stated that there was no assessment documented.
Surveyor asked if staff was expected to perform a skin assessment for R15 when he returned from the hospital. IDON X stated yes.
On 4/17/25 at 9:16 AM, Surveyor observed R15's right heel with IDON X.
Wound bed measured 5 cm (centimeter) length by 2.5 cm width with pale center of wound bed and slough around the edges.
On 4/17/25 at 3:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if staff is expected to complete a skin assessment when a resident returns from the hospital. NHA A stated yes.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
is expected to perform nightly foot checks for diabetic resident. NHA A stated yes.
the right tibia, fibula, and medial malleolus, (a serious ankle fracture) and dementia.
R16's 3/24/25 Brief Interview for Mental Status (BIMS) score is a 15, indicating R16 is cognitively intact.
R16's Physician orders include diabetic foot check nightly at bedtime for diabetes.
Start date 7/10/24.
R16's Treatment Administration Record (TAR) indicates diabetic foot check nightly at bedtime for diabetes.
Diabetic foot checks were not completed on the following days based on R16's TARs.
R16's January 2025 TAR indicated on January 16, 17, and 18, R16's diabetic foot checks were not completed.
R16's February 2025 TAR indicated on February 7, 8, 9, 10, 24, and 27, R16's diabetic foot checks were not completed.
R16's March 2025 TAR indicated on March 5, 8, 12, and 13, R16's diabetic foot checks were not completed.
On 4/16/25 at 3:15 PM, Surveyor interviewed LPN W (Licensed Practical Nurse) regarding diabetic foot checks. LPN W indicated if the order was on the TAR she would have completed a diabetic foot check.
Surveyor asked LPN W if she had completed a diabetic foot check for R16, and LPN W indicated she had completed diabetic foot checks for R16. LPN W indicated she could not recall anything in particular with R16's foot checks.
When asked if LPN W could recall wounds or open areas to R16's feet, LPN W could not recall. LPN W indicated R16 would become agitated if staff approached him when he was in bed, so many times the diabetic foot check would be rushed and not as thorough as it should be.
Of note, Podiatry had placed a gauze dressing to R16's foot on 3/14/25 and the same dressing was on R16's foot on 3/18/25 during the follow up appointment with podiatry. LPN W signed out the TAR as completing a diabetic foot check for R16 on 3/15/25 and 3/16/25 and was unable to recall any concerns about R16's foot.
On 4/17/25 at 10:19 AM, Surveyor interviewed IDON X (Interim Director of Nursing) regarding diabetic foot checks. IDON X indicated she would expect diabetic foot checks to be completed as ordered and to be signed out in the TAR. IDON X indicated if there was an abnormality found or something unusual, there would be a progress note indicating what was found/observed.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
facility did not implement 1:1 supervision or any additional interventions to increase supervision for
The facility did not provide a policy and procedure for power wheelchair charging.
R1 was admitted to the facility on [DATE] with diagnoses that include Type 2 diabetes mellitus with foot ulcer, muscle weakness, morbid obesity, dysphagia, pressure ulcer stage 3, nicotine dependence, mild cognitive impairment, and polyneuropathy.
R1's most recent MDS (Minimum Data Set) dated 2/16/25 states R1 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating R1 is cognitively intact.
On 4/3/25 at 10:43, AM Surveyor observed R1's power wheelchair to be charging in R1's room. R1 disconnected his powerchair and indicated he charges his chair over there as he pointed to the outlet with the charging cord hanging from it.
On 4/3/25 at 11:41 AM, NHA A and Surveyor observed R1's room where his wheelchair had been charging and where now only the charging cord was attached to the outlet. NHA A stated, The chair should not be charging in here. It should be in the charging room. NHA A disconnected the cord from the outlet and removed it from R1's room. NHA A indicated the facility does not have a policy related to power wheelchair charging.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
would be the nursing department that does that assessment.
Surveyor asked MD M if he had done any
MD M stated he had never measured the gaps for the mattresses.
Surveyor asked MD M how he ensured that the dimensions of the bed were appropriate for the resident's size and weight. MD M indicated that would be therapy or nursing that would do that.
Surveyor asked MD M how often was scheduled maintenance or audits completed on the bed rails already in use. MD M stated that he completes a walk around inspection of the facility weekly and tries to check the bed rails at that time to make sure they are working properly.
Surveyor asked MD M if he had documentation of bed rail maintenance. MD M indicated that information was all kept in their online maintenance system, and he did not have any logs or documentation of that.
On 4/3/25 at 3:49 PM, Surveyor interviewed DON B (Director of Nursing) and asked how she assessed the resident for risk of entrapment prior to installing or using bed rails. DON B stated that it was maintenance that would go around and do measurements.
Surveyor asked DON B how often maintenance should be doing measurements and completing audits on the bed rails. DON B indicated that their policy stated they should be done quarterly.
Surveyor asked DON B how often bed rail assessments should be completed on the bed rails already in place. DON B stated those should be done quarterly also, but that they hadn't been completed since last May.
Surveyor asked DON B if it was her expectation that they be completed quarterly. DON B stated yes, that would be her expectation.
Surveyor asked DON B if the resident or family representative actually signs the bed rail assessment. DON B indicated that residents and/or family members don't physically sign, but when they have the discussion with them, they just type in their name.
Surveyor asked DON B if there were any entrapment assessments. DON B indicated no; she did not see an assessment for that.
Surveyor asked DON B what kind of education or risk, and benefits was completed with the residents and or family members for the use of side rails with air mattresses. DON B stated that they were told of the risks and benefits, but that she did not have any documentation of it. DON B pulled up a bed rail assessment on her computer and expanded field 3A, which indicated the following, The positive and negative aspects of side rail/assist bar have been discussed with the resident and/or family, and the resident and/or responsible parties are aware of the risk involved with the side rail use.
Surveyor asked DON B if she had any documentation that listed what those risks were. DON B stated that she thought there was something but that she couldn't find it.
Surveyor asked DON B if any alternatives are tried before installing the bed rails. DON B indicated that they use the assessments, such as the bed rail assessment, fall risk assessment, Braden scale, a lift transfer evaluation, fall risk assessment, elopement assessment and ADL (Activities of Daily Living) assessment.
Surveyor asked DON B how she would ensure the correct use of an installed bed rail. DON B said that would be the maintenance department.
Surveyor asked DON B who would be responsible for measuring the gap between the side rail and the air mattress to reduce the risk of entrapment. DON B said that would be maintenance.
Surveyor asked DON B who assesses to determine that the bed dimensions are appropriate for the resident size and weight. DON B said that would be maintenance too.
Surveyor asked DON B if the measurements for gaps with the mattress and bed rails, a bed rail assessment that the resident or family signed, and written proof of risk vs. benefits for bed rails should be part of the resident's electronic medical record. DON B stated yes, it should all be included in the medical record.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
processing times for new orders. MD V indicated any order placed in the system by 5:00 PM, the
of antibiotics was not given until 3/8/25.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
potential to affect more than a minimal number of Residents (R).
2 of 2 test trays were served outside of temperature range.
Evidenced by: The facility policy, titled Food Safety Requirements, dated 10/1/22, includes in part: .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety .
Police Explanation and Compliance Guidelines . 4.
When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards . d.
Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained.
Staff shall refer to the current FDA (Food and Drug Administration) Food Code and facility policy for food temperatures as needed . 5.
Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone.
Strategies include, but are not limited to: . f.
Timely distribution of all meals/snacks .
Facility policy, titled Date Marking for Food Safety, undated, includes in part: . refrigerated, ready to eat, TCS (time/temperature control for safety) food shall be held at a temperature of 41°F (Fahrenheit) or less .
Example 1 On 4/3/25 at 8:45 AM, Surveyor received a breakfast test tray after all the dining room and hall trays had been served. (Of note, plates were being covered by plastic tops and bottoms, but no plate warmers were being used.
The milk was poured into glasses and covered but were being kept on a tray without ice).
Surveyor took the temperatures of the food that was served, including scrambled eggs, oatmeal, milk and coffee.
Surveyor noted that the milk was in the temperature danger zone (temperature of 53.2 degrees F) and tasted warm.
Example 2 On 4/3/25 at 12:35 PM, Surveyor received a lunch test tray.
Surveyor took the temperatures of the food that was served, including Salisbury steak, mashed potatoes and gravy, beets and milk.
Surveyor noted again that the milk was in the temperature danger zone (temperature 48 degrees F) and tasted warm. (It is important to note the milk should be held at 41 degrees F or less.) On 4/3/25 at 8:54 AM, Surveyor interviewed DM D (Dietary Manager) and asked what the safe temperature was for serving hot and cold foods. DM D stated that hot foods should be served between 135 - 160 degrees F. DM D stated that cold foods should be served between 40 - 55 degrees F.
Surveyor explained that cold foods should be kept below 41 degrees F and asked if she would expect food to be served at a safe and palatable temperature. DM D stated yes, that would be her expectation.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
serve food in accordance with professional standards.
environment in which food is prepared, stored, and distributed.
This has the potential to affect all 41
Surveyor observed food that had been removed from the original box to be undated and unlabeled.
Surveyor observed milk to be opened with no open date.
Surveyor observed magic cups to be thawed and without a thaw date.
Evidenced by: Facility policy titled Date Marking for Food Safety, undated, includes: the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.
The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.
The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly.
On 4/3/25 at 8:30 AM, Surveyor observed 3-gallon size white milks to be opened without an open date, mandarin oranges to have been removed from the original container without an open date or an expiration date, barbecue sauce opened with no open date, and 5 thawed magic cups with no thaw dates on them.
On 4/3/25 at 9:00 AM, DM D (Dietary Manager) indicated magic cups need to be labeled with thaw dates and all food or drink that is opened needs to be labeled with open dates. DM D indicated she was unsure when the milk was opened, when the mandarin oranges were opened, when the barbecue was opened, and when the magic cups were pulled from the freezer.
On 4/3/25 at 9:10 AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated food removed from the manufacturer's packaging needs to be labeled with a use by date or an opened date, opened milk needs to be labeled with an open date, and magic cups need a thaw date on them.
525321 04/21/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
transfers and did not.
On 4/17/25 at 2:10 PM, Surveyor spoke with VPC S (Vice President of Clinical) regarding infection control. VPC S indicated staff should wear PPE for residents that have EBP.
Example 2 R15 was admitted to the facility on [DATE] and has diagnoses that include pressure ulcer of right heel (localized injury to the skin and underlying tissue caused by prolonged pressure); chronic venous hypertension with ulcer of right lower extremity (a condition where the veins in the legs have consistently high pressure, which can lead to swelling, skin changes and leg ulcers/wounds); varicose veins of unspecified lower extremity with ulcer other part of lower leg (swollen, twisted veins that prevent blood from flowing back to the heart effectively, which can cause swelling and skin discoloration or ulcers/wounds.
R15's Care Plan states, in part: Focus-Infection actual or at risk for related to: enhanced Barrier Precautions (wounds) .Interventions/Tasks .Wear appropriate PPE date initiated 7/22/24.
On 4/17/25 at 9:16 AM, Surveyor observed R15's wound with IDON X (Interim DON). IDON X picked up R15's right leg and removed the bandage wrap. IDON X set down R15's leg, went into the bathroom, applied a set of gloves, returned to R15 and removed the border dressing to observe the wound.
Surveyor asked IDON X about the cart sitting outside of R15's room. IDON X stated it was there to hold a supply of PPE for residents with wounds or catheters.
Surveyor asked when the PPE would be used for R15. IDON X stated it would be used for any wound care.
Surveyor asked if PPE is required when removing a dressing. IDON X stated yes, gloves.
Surveyor asked if a gown is required. IDON X stated no, unless the resident has a positive wound culture or excessive drainage.
On 4/17/25 at 9:49 AM, Surveyor interviewed VPC S (Vice President of Clinical) and asked if any precautions are required when working with wounds. VPC S stated EBP; gowns and gloves when touching the resident.
Surveyor asked if gown and gloves are required for removal of R15's wound dressing. VPC S stated yes.
On 4/17/25 at 3:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if staff is expected to wear a gown and gloves for removal of a wound dressing while on EBP. NHA A stated yes.
The facility failed to re-assess R3's risk of entrapment, complete a safety/gap test with the air mattress, provide written documentation of ongoing monitoring of bed rails, and provide documentation of alternatives tried prior to installing bed rails.
The facility failed to re-assess R7's risk of entrapment, complete safety/gap tests with the air mattress, provide written documentation of ongoing monitoring of bed rails, provide documentation of alternatives tried prior to installing bed rails, and provide evidence of the individual risk and benefits that were reviewed.
The facility failed to assess R10's risk of entrapment, complete safety/gap tests with the air mattress, provide written documentation of ongoing monitoring of bed rails, provide documentation of alternatives tried prior to installing bed rails, and provide evidence of the individual risk and benefits that were reviewed.
Evidenced by
The facility policy, Proper Use of Bed Rails, dated 10/1/22, states, in part:
Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails.
Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.
Definitions: Bed Rails .
Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars .
525321
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525321 B.
Wing 04/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.