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Complaint Investigation

Wisconsin Rapids Health Services

October 6, 2025 · Wisconsin Rapids, WI · 1350 River Run Dr
Citations 4
CMS Rating 1/5
Beds 114
Provider ID 525212
Healthcare Facility
Wisconsin Rapids Health Services
Wisconsin Rapids, WI  ·  View full profile →
Inspection Summary

Wisconsin Rapids Health Services in Wisconsin Rapids, WI — inspection on October 6, 2025.

Found 4 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.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R7) of 2 sampled residents.R8 reported to staff on 9/3/25 that Certified Nursing Assistant (CNA)-E yelled at R7 (who was R8's spouse).

The facility did not report the allegation of abuse to the SA.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV.

Identification of Abuse, Neglect, and Exploitation: .B.

Possible indicators of abuse include, but are not limited to: Verbal abuse of a resident overheard or inappropriate verbal conduct overheard .VII.

Reporting Response.

The facility will have written procedures that include: 1.

Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. B.

Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B.

The Administrator will follow-up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by State Agencies. On 10/6/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and dysphagia. A Minimum Data Set (MDS) assessment completed 9/10/25 included a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment. On 10/6/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD). An MDS assessment completed 1/31/22 included a BIMS score of 15 out of 15 which indicated R8 was not cognitively impaired. On 10/6/25, Surveyor reviewed a grievance, reported by R8 and dated 9/3/25, that indicated CNA-E yelled at R7 (who was R8's spouse) on 9/2/25 for getting out of bed. An alarm was activated when R7 was watching TV in a wheelchair and attempted to get the remote.

CNA-E entered the room and yelled at R7.

The grievance form indicated Nursing Home Administrator (NHA)-A investigated the grievance.

Staff had no follow-up or further information and did not confirm or deny the incident.

The writer discussed being firm with a resident who puts themself at risk and the perception of coming across as yelling.

The form indicated the grievance was resolved on 9/20/25. On 10/6/25 at 1:22 PM, Surveyor interviewed NHA-A who confirmed NHA-A did not report the allegation of abuse to the SA. NHA-A indicated NHA-A knew R7, R8, and CNA-E and felt CNA-E's tone was taken wrong. NHA-A indicated CNA-E is not a soft person and it sounded like CNA-E entered the room with intensity which was perceived as yelling. NHA-A agreed the allegation of abuse should have been reported to the SA.

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 REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Wisconsin Rapids Health Services

1350 River Run Dr Wisconsin Rapids, WI 54494

SUMMARY STATEMENT OF DEFICIENCIES

Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. VI.

Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation.On 10/6/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and dysphagia. A Minimum Data Set (MDS) assessment completed 9/10/25 included a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment.On 10/6/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD). An MDS assessment completed 1/31/22 included a BIMS score of 15 out of 15 which indicated R8 was not cognitively impaired.On 10/6/25, Surveyor reviewed a grievance, reported by R8 and dated 9/3/25, that indicated CNA-E yelled at R7 (who was R8's spouse) on 9/2/25 for getting out of bed. An alarm went off when R7 was watching TV in a wheelchair and attempted to get the remote. CNA-E entered the room and yelled at R7.

The grievance form indicated Nursing Home Administrator (NHA)-A investigated the grievance.

Staff had no follow-up or further information and did not confirm or deny the incident.

Staff had no comment when the writer discussed being firm with a resident who puts themself at risk and the perception of coming across as yelling.

The form indicated the grievance was resolved on 9/20/25. On 10/6/25 at 1:22 PM, Surveyor interviewed NHA-A who confirmed NHA-A did not complete a thorough investigation for the allegation of verbal abuse. NHA-A indicated NHA-A knew R7, R8, and CNA-E and thought CNA-E's tone was taken wrong. NHA-A indiated CNA-E is not a soft person and it sounded like CNA-E entered the room with intensity which was perceived as yelling. NHA-A stated NHA-A talks with staff frequently about checking themselves at the door prior to entering a resident's room.

NHA-A agreed the allegation of abuse should have been thoroughly investigated, including resident and staff interviews and staff education.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Wisconsin Rapids Health Services

1350 River Run Dr Wisconsin Rapids, WI 54494

SUMMARY STATEMENT OF DEFICIENCIES

insulin with an injectable pen, the pen should be held to the skin for 10 seconds after pressing the injection button.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Wisconsin Rapids Health Services

1350 River Run Dr Wisconsin Rapids, WI 54494

SUMMARY STATEMENT OF DEFICIENCIES

lifts but occasionally gives them a quick look over. MD-F stated the lookover is not documented on MD-F's spreadsheet for inspections or battery rebuilds. MD-F was aware staff were sharing a remote between lifts and indicated the rented bariatric EZ stand and bariatric Hoyer lift could share a remote. MD-F indicated it doesn't take long to get a remote and was not sure why a new remote did not arrive right away. MD-F verified MD-F was notified that the bariatric Hoyer lift didn't work but could not recall the date. MD-F indicated the rental company came in and swapped the bariatric Hoyer lift. In a subsequent interview at 12:55 PM, MD-F confirmed the issue with the lifts started approximately 2 weeks prior when a remote stopped working. MD-F confirmed NHA-A got involved when the lift stopped working entirely.

Surveyor and MD-F then went to the storage room.

When Surveyor indicated the rented bariatric EZ stand lift did not work, MD-F tried to turn on the lift. MD-F verified the lift did not work and was not sure why.On 10/6/25 at 11:08 AM, Surveyor interviewed Rental Company Staff (RCS)-I who stated NHA-A contacted the company on 9/22/25 and indicated the lift battery was fully charged but the lift didn't work. RCS-I indicated the company picked up the lift that day at 5:42 PM and a new bariatric lift was delivered on 9/23/25 at 5:43 PM.

On 10/6/25 at 4:30 PM, Surveyor interviewed CNA-J via phone. CNA-J indicated the bariatric Hoyer lift did not work on 9/21/25 which affected one resident who was no longer at the facility. CNA-J could not recall the resident's name. CNA-J stated the resident usually got up to eat but had to stay in bed because the lift didn't work. CNA-J did not recall if R1 asked to get up. CNA-J informed the nurse when the lift stopped working and stated CNA-J probably should have initiated a work order.On 10/6/24 at 1:24 PM, Surveyor interviewed NHA-A who confirmed a rented bariatric lift stopped operating on the weekend of 9/21/25.

NHA-A contacted the company and thought it only affected one resident. NHA-A was not aware that R1 was affected and stated R1 did not choose to get up every day.

When NHA-A learned staff had been sharing a controller and asked why the company did not send a new controller for the lift, the company brought a new lift to the facility. NHA-A had not completed staff education on how to report issues so they are resolved timely.

Surveyor informed NHA-A that there was a broken bariatric EZ stand lift in the storage room on R1's unit and confusion between staff regarding which lifts worked.

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 Wisconsin Rapids, 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 Wisconsin Rapids Health Services or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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