Rivers Edge Nursing And Rehab

F 0609 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

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

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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivers Edge Nursing and Rehab

1000 N. Wisconsin Ave.

Muscoda, WI 53573

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

RN R (Registered Nurse) sent Resident R4 out on 7/29/25, NHA A indicated Power of Attorney stopped at the facility

after Resident R4 went out and indicated Resident R4 was not doing well. NHA A indicated she called the hospital Friday, and hospital returned her call on Saturday. NHA A indicated the hospital told her Resident R4 had passed away due to sepsis. NHA A indicated she started a self-report investigation because Resident R4 was diagnosed with sepsis and passed away. NHA A indicated she did not interview any staff, did not complete any house audits, and did not provide any education regarding this incident. NHA A indicated she would expect nursing to report changes in condition to primary physician and complete assessments.

It is important to note that Surveyors discovered through staff interviews and record review concerns with change of condition, assessments, and physician notification.

The facility failed to complete a thorough investigation for the reported incident involving Resident R4.

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

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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivers Edge Nursing and Rehab

1000 N. Wisconsin Ave.

Muscoda, WI 53573

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

Left Thigh

Level of Harm - Immediate jeopardy to resident health or safety

7/7/25: 3.2 x 0.7 x 0.5 tunnel

Residents Affected - Few

7/21/25: 0.5 x 0.5 x 0.1

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 Resident 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 Resident R5 was seen by a PA (Physician Assistant). The PA documented Reason for visit: Advanced Directives Plans: Anemia, Multiple wounds,

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

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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivers Edge Nursing and Rehab

1000 N. Wisconsin Ave.

Muscoda, WI 53573

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 12 sampled residents (Resident R9). Resident R9 voiced concern of being transferred 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: Resident R9 was admitted to the facility on [DATE REDACTED] with diagnoses that include: Spina bifida, Type 2 Diabetes Mellitus without complications, asthma, chronic systolic (congestive) heart failure, and cardiomyopathy (heart muscle disease). Resident R9's most recent Minimum Data Set (MDS) dated [DATE REDACTED] indicates a staff assessment was conducted for a Brief Interview of Mental Status (BIMS). Staff assessment indicated that Resident R9's memory was OK. Section GG of the MDS, states that Resident R9 requires total dependence on staff for toileting, showering, and transfers. Resident 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 Resident R9 and asked about her care at the facility. Resident R9 stated sometimes only 1 CNA (Certified Nursing Assistant) uses the Hoyer lift with her and this happens on PM shift. Resident 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 Resident R9. CNA C indicated he has transferred Resident R9 with the Hoyer alone. It is important to note Resident R9's care plan states Resident 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.

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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivers Edge Nursing and Rehab

1000 N. Wisconsin Ave.

Muscoda, WI 53573

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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Surveyor observed RN J (Registered Nurse) administer the eighteen (18) medications above to Resident R12. This resulted in 18 medication errors due to timing (late administration). Example 2R5's Physician Orders, signed 8/7/25, include, in part, the following medications:19. Aspirin 81 mg (milligrams) - Give 1 tablet by mouth in the morning related to peripheral vascular disease Resident R5's Medication Administration Record) indicates Aspirin is scheduled to be administered at 8:00 AM.20. Divalproex ER (extended-release) 250 mg (milligrams) - Give 1 capsule by mouth in the morning related to depression. Resident R5's MAR indicates Divalproex ER is scheduled to be administered at 8:00 AM.21. Levetiracetam Oral tablet 500 mg - Give 2 tablets by mouth two times a day for seizuresR5's MAR indicates Levetiracetam is scheduled to be 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.Resident 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 Resident 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, Resident R12 and Resident R5's medications should be administered within 1 hour

before and 1 hour after the scheduled time on the MAR.

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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivers Edge Nursing and Rehab

1000 N. Wisconsin Ave.

Muscoda, WI 53573

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 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors, for 1 of 2 residents reviewed for significant medication errors (Resident R5).Surveyor observed RN J (Registered Nurse) crush Resident R5's Divalproex (Depakote) extended- release and administered it to Resident R5. Evidenced by:The facility policy, entitled, Medication Administration, dated 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.Resident 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 Resident R5's Divalproex Extended-Release 250 mg tablet and administer it to Resident 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 Resident R5's Divalproex. DON B reviewed Resident R5's physician orders. DON B stated, Resident R5 does not have a physician order to crush Divalproex extended release. Surveyor asked DON B, is it acceptable for nurses to crush Resident 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 Resident R5.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet