Rivers Edge Nursing And Rehab
Rivers Edge Nursing and Rehab in Muscoda, WI — inspection on August 25, 2025.
Found 6 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
authorities.
interview and record review, the facility did not ensure that all alleged violations involving abuse,
to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 16 residents (R10) reviewed for abuse.Multiple staff made an allegation that a staff member was mentally abusing R10, and the facility did not report the allegation to the State Survey Agency.evidenced by:According to the State Operations Manual, as described in S483.70(o)(2)(ii)(J), The nursing home must follow all of the requirements within S483.12(a)(b) and (c), Free From Abuse.for the prevention, identification, protection, reporting and investigation of allegations of abuse, neglect, verbal, mental, sexual abuse, mistreatment and injuries of unknown source.
This also includes prohibiting taking and/or posting photos or recordings that are demeaning and or humiliating to a nursing home resident or the use of an authorized photo or recording in a demeaning/humiliating manner.The facility's abuse policy states, Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes.R10 was admitted to the facility on [DATE] and has diagnoses that include Parkison's disease. R10 has a guardian in place.An anonymous complaint was received by the state agency stating that CNA O (Certified Nursing Assistant) had been taking videos and pictures of R10.
Documentation received from the facility on 8/25/25 includes statements from staff CNA C, CNA T, LPN G (License Practical Nurse), and LPN U.
Statements from these staff all indicated that they had seen CNA O taking videos and pictures with R10 at the nurse's station in the evening on 8/12/25.
CNA C's statement states, in part, She (CNA O) was telling R10 to work it and dance baby dance. CNA C's statement goes on to say that he, LPN G and LPN U had seen this and felt they needed to contact NHA A (Nursing Home Administrator), who then requested that they write statements.Surveyors were unable to get into contact with CNA C or CNA T.On 8/25/25 at 11:46 AM, Surveyor interviewed LPN G who stated that R10 does like to dance, and he has some very spastic-like movements due to his Parkinson's. LPN G stated that when she saw CNA O recording R10, she thought it was inappropriate and demeaning to R10.On 8/25/25 at 2:31 PM, Surveyor interviewed LPN U who stated that she witnessed CNA O recording R10 for 5 minutes. LPN U then showed Surveyor a picture she took of CNA O taking a selfie of herself and R10. LPN U stated she did not want to get in trouble, so she did not share the picture with administration. LPN U stated she believed CNA O was taking Snapchats of R10 dancing.On 8/25/25 at 2:15 PM, CNA O denied recording R10.R10 refused to speak with Surveyors.On 8/25/25 at 3:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that she was unable to prove that any abuse had happened.
When asked if an allegation that a staff member was recording a resident would be considered potential abuse, NHA A stated, Yes.
When asked why she did not submit an initial abuse report to the State Survey Agency, NHA A stated that she investigated the allegation and could not substantiate the allegation, so she did not report it.The facility did not submit a report to the State Survey Agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
525321 08/25/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
The facility failed to complete a thorough investigation for the reported incident involving R4.
525321 08/25/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
jeopardy to resident health or safety 7/14/25: 3.2 x 1.0 x 2.0
Left Shoulder 7/14/25: 2.5 X 1.5 Right Second Toe 7/14/25: 0.2 x 0.2 7/21/25: 0.5 x 0.3 Right Great Toe 7/14/25: 0.5 x 0.3 R5’s physician orders for wounds are as follows: 7/5/25 Wound Care Left Posterior Shoulder – Cleanse wound, and peri wound area with wound cleanser, pat dry; Paint wound with betadine; Leave OTA (open to air) – every day shift 7/5/25 Wound Care Right Foot – First/Second Toe – Cleanse wound with wound cleaner.
Pat dry; Paint with Betadine; Leave OTA (open to air) – every day shift 7/7/25 Wound Care Left Lateral Hip – Cleanse wound, and peri wound with wound cleanser.
Pat dry: Pack wound with iodoform gauze packing strips or sterile gauze FLUFFED; Cover with gauzed border dressing – island dressing - every day shift 7/31/25 Referral to wound care clinic. *Left hip wound with tunneling 8/8/25 Change wound dressing to 3x (times) week.
Cleanse wound and apply dressing such as Mepilex – every day shift Monday, Wednesday, Friday for wound care On 7/31/25 R5 was seen by a PA (Physician Assistant).
The PA documented Reason for visit: Advanced Directives Plans: Anemia, Multiple wounds,
525321 08/25/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
prevent accidents.
interview, and record review, the facility did not ensure adequate supervision and safety to prevent
with a Hoyer lift and only one staff present.
This is evidenced by: Facility policy titled, Transfer Status dated 1/2025, states in part: It is a policy to ensure safe, consistent, and resident-centered transfer practices for all long-term care residents, minimizing risk of injury to residents, staff, and visitors, while maintaining dignity and compliance .Hoyer Lift - A mechanical lift used when resident requires full or partial support.All mechanical lifts require the assistance of 2.
Example 1: R9 was admitted to the facility on [DATE] with diagnoses that include: Spina bifida, Type 2 Diabetes Mellitus without complications, asthma, chronic systolic (congestive) heart failure, and cardiomyopathy (heart muscle disease). R9's most recent Minimum Data Set (MDS) dated [DATE] indicates a staff assessment was conducted for a Brief Interview of Mental Status (BIMS).
Staff assessment indicated that R9's memory was OK.
Section GG of the MDS, states that R9 requires total dependence on staff for toileting, showering, and transfers. R9's Comprehensive Care Plan states, in part: Focus: I have a physical functioning deficit related to: mobility impairment, self care impairment, DX (diagnosis) spina bifida, DM (diabetes mellitus), asthma, OA (osteoarthritis), migraine, muscle weakness, TBI (traumatic brain injury) obesity, hx (history) falls.date initiated 9/26/2021.
Interventions: .Hoyer to Broda chair, ensure patient and staff safety. 2 assist.date initiated 12/9/24, revision on 5/1/2025. On 8/12/25 at 10:45 AM, Surveyor interviewed R9 and asked about her care at the facility. R9 stated sometimes only 1 CNA (Certified Nursing Assistant) uses the Hoyer lift with her and this happens on PM shift. R9 stated she knows there are supposed to be 2 people when using the lift. On 8/12/25 at 2:20 PM, Surveyor interviewed CNA C (Certified Nursing Assistant), who usually works PM shift, about transferring residents with a Hoyer lift.
Surveyor asked CNA C if he uses one or two staff with the Hoyer lift in this facility. CNA C indicated there's not always enough staff and stated he tries to have 2 people with a Hoyer transfer, tries to get help but can't, and sometimes he uses it alone. CNA C stated, It depends on the resident. We can use it with one or two.
Surveyor asked CNA C who he can transfer with the Hoyer alone and CNA C stated R9. CNA C indicated he has transferred R9 with the Hoyer alone. It is important to note R9's care plan states R9 is a Hoyer transfer with 2 assist and facility transfer policy states all transfers with a mechanical lift are to be with 2 people. On 8/13/25 at 1:38 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if she expected staff to follow the transfer policy and follow resident care plans. DON B stated yes, she expected staff to follow the facility policy for safe transfers using the Hoyer with two staff members and would expect staff to follow resident care plans. On 8/13/25 at 2:50 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked her if she expected staff to follow facility policies regarding safe transfers. NHA A stated yes, she expected the policy to be followed for Hoyer transfers and that they should always have two staff members to assist when using the Hoyer.
525321 08/25/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
the morning related to peripheral vascular disease R5's Medication Administration Record) indicates
Divalproex ER is scheduled to be administered at 8:00 AM.21.
Levetiracetam Oral tablet 500 mg - Give
administered at 8:00 AM and 8:00 PM.22.
Potassium Chloride ER (extended release) - Give 2 capsules by mouth two times a day for K replacementR5's MAR indicates Potassium Chloride ER is scheduled to be administered at 8:00 AM and 5:00 PM. 23.
Sodium Chloride 1 gm (gram) - Give 1 tablet by mouth three times a day for supplement.R5's MAR indicates Sodium Chloride is scheduled to be administered at 8:00 AM, Noon, and 5:00 PM.24.
Lisinopril 20 mg - Give 1 tablet by mouth by mouth in the morning for hypertensionR5's MAR indicates Lisinopril is scheduled to be administered at 8:00 AM. On 8/13/25 at 11:00 AM, Surveyor observed RN J (Registered Nurse) administer the six (6) medications above to R5.
This resulted in 6 medication errors due to timing (late administration).On 8/14/25 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing).
Surveyor informed DON B of the medication error rate of 100.00% due to late medication administration.
Surveyor asked DON B, if she expects staff to follow Physician orders. DON B stated, Yes.
Surveyor asked DON B, if a medication is scheduled to be administered at 7:00 AM, when would you expect staff to administer the medication. DON B stated, between 6:00 AM - 8:00 AM.
Surveyor asked DON B, if a medication is scheduled for 7:30 AM, when would you expect staff to administer the medication. DON B stated, 6:30 AM - 8:30 AM.
Surveyor asked DON B, if a medication is scheduled to be administered at 8:00 AM, when would you expect staff to administer the medication. DON B stated, between 7:00 AM - 9:00 AM. DON B stated, when medications are scheduled for a specific time on the MAR (Medication Administration Record) staff have 1 hour before and 1 hour after the scheduled time to administer the medication. DON B stated, R12 and R5's medications should be administered within 1 hour before and 1 hour after the scheduled time on the MAR.
525321 08/25/2025
Rivers Edge Nursing and Rehab 1000 N.
Wisconsin Ave.
Muscoda, WI 53573
(R5).Surveyor observed RN J (Registered Nurse) crush R5's Divalproex (Depakote) extended- release
3/1/19, states in part: Administer medication as ordered in accordance with manufacturer specifications.Crush medications as ordered. Do not crush medications with do not crush instructions.R5's Physician Orders, signed 8/7/25, include, in part, the following medication:Divalproex Sodium ER (Extended Release) Oral Tablet 24-hour 250 mg (milligrams) - Give 1 tablet by mouth in the morning for seizures.
Divalproex Sodium ER (Extended Release) Oral Tablet 24-hour 250 mg (milligrams) - Give 2 tablets by mouth in the evening for seizures. On 8/13/25 at 11:00 AM, Surveyor observed RN J (Registered Nurse) crush R5's Divalproex Extended-Release 250 mg tablet and administer it to R5. It is important to note, extended-release medications are not to be crushed.On 8/13/25 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing).
Surveyor asked DON B, if she expects staff to follow Physician orders. DON B stated, Yes.
Surveyor asked DON B, is it acceptable for Divalproex extended release to be crushed. DON B stated, It should not be crushed or chewed.
Surveyor asked DON B if there is a physician order to crush R5's Divalproex. DON B reviewed R5's physician orders. DON B stated, R5 does not have a physician order to crush Divalproex extended release.
Surveyor asked DON B, is it acceptable for nurses to crush R5's Divalproex extended-release tablet. DON B stated, No. On 8/13/25 at 12:45 PM, DON B (Director of Nursing) stated, the MD (Medical Doctor) will order liquid Divalproex ER (extended release) for R5.
Frequently Asked Questions
More Reports
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.