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Complaint Investigation

Tomah Nursing And Rehab

December 22, 2025 · Tomah, WI · 1505 Butts Ave
Citations 1
CMS Rating 1/5
Beds 74
Provider ID 525442
Healthcare Facility
Tomah Nursing And Rehab
Tomah, WI  ·  View full profile →
Inspection Summary

TOMAH NURSING AND REHAB in TOMAH, WI — inspection on December 22, 2025.

Found 1 citation. 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.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

the baseboard heat registries to ensure they are not at risk for burns.

Resident beds will maintain a safe distance away from the baseboard heat registries.

Resident recliners will be positioned in a way that does not put them at risk to come in contact with a baseboard heat registry.

Concerns with any baseboard heat registry will be brought to the Maintenance Lead or Administrator's attention and receive prompt follow-up.

Effective Date: 12/10/25The deficient practice continues at a scope and severity of E (potential for harm/pattern) related to the examples of R9, R10, and R11 and as the facility continues to implement its action plan:3. R9 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, muscle weakness (generalized), contracture of muscle (permanent shortening and tightening of muscle fibers leading to reduced flexibility and difficulty moving), multiple sites, low back pain, history of falling, tremor, dementia, and osteolysis (bone degeneration). R9's most recent Minimum Data Set with Assessment Reference Date of 11/10/25 indicated R9 has a BIMS score of 00 out of 15 indicating severe cognitive impairment.

Section GG indicated R9 utilizes a wheelchair for mobility and is independent with rolling left and right including all other mobility except for tub/shower transfers, which he is dependent on staff, and walking 10 feet which was not attempted due to R9's current illness, exacerbation, or injury. R9's Comprehensive Care Plan indicated in part:Problem: Resident requires assistance for ADLs (Activities of Daily Living) r/t (related to) weakness and diagnosis of dementia.

Approaches include, in part: .Mobility: Independent wheelchair.

Start Date: 8/22/23.

Bed Mobility: Independent.

Start Date: 8/22/23.

Transfers: Assist of 1. He does self-transfer at times.

Start Date: 5/27/24.On 12/9/25 at 3:40, Surveyors observed R9's room and noted he has his room temperature set to 75 F.

Two Surveyors both touched R9's baseboard heater and both had to pull their hands away immediately due to the baseboard heater being so hot.

Surveyors also noted that the bed was touching the baseboard heater at the time of observation and R9 was laying in the bed. R9, who gave permission for Surveyors to observe his baseboard heater, stated that the wall is hotter than hell. R9, who had his bed in the low position, also indicates his fingers have accidentally touched the baseboard heater while he was sleeping and it makes him jump because the baseboard heater is so hot. On 12/9/25 at 4:35 PM, LPN C (Licensed Practical Nurse) went to R9's room with Surveyor.

Surveyor asked LPN C what she thought of the distance between R9's bed and the baseboard heater. LPN C indicated the bed and the baseboard heater were too close together. On 12/10/2

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TOMAH, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from TOMAH NURSING AND REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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