Inspection Reports for Careview Health and Rehab of Minocqua

The inspection was conducted based on complaints regarding inadequate wound care and failure to implement physician orders for a resident (R1) admitted with a severe wound and complex medical needs.

The facility failed to provide ordered wound care, including the application of a wound VAC and administration of vancomycin solution, resulting in contamination of the wound with stool and significant resident pain. Additionally, the facility did not develop a baseline care plan for wound care within 48 hours of admission and did not ensure treatment was provided according to professional standards and physician orders.

The complaint investigation revealed that the facility did not provide wound care as ordered for resident R1, including failure to order and apply a wound VAC and administer vancomycin solution. The wound became contaminated with stool, causing significant pain. The facility also failed to develop a baseline care plan for wound care within 48 hours of admission. The resident was sent to the hospital for wound care and did not return to the facility.

The inspection was conducted as a complaint investigation regarding the facility's failure to designate a registered nurse as the Director of Nursing and issues related to nurse staffing waivers and call light system functionality.

The facility did not have a registered nurse serving as the Director of Nursing, which affected all 48 residents. The facility failed to request a waiver for this staffing deficiency and did not respond to the State Agency's requests. Additionally, the call light system was not functioning properly, causing delays in staff response to resident calls.

The complaint investigation was triggered by concerns that the Director of Nursing was not a registered nurse as required, and issues with nurse staffing and call light system functionality. The complaint was substantiated with findings of noncompliance.

The inspection was conducted due to a complaint investigation regarding failure to provide timely cardiopulmonary resuscitation (CPR) and other care deficiencies related to medication administration, IV fluid management, and quality assurance processes.

The facility failed to provide timely CPR to a resident found unresponsive, delayed administration of critical medications including vancomycin, failed to document and order appropriate PICC line care, administered medications outside prescribed timeframes, and did not identify or investigate an adverse event related to an unwitnessed fall resulting in death. The facility also lacked evidence of quality assurance review for these incidents.

The complaint investigation focused on the failure to provide CPR timely to Resident 1 found unresponsive, medication administration errors including missed doses and delayed administration, inadequate PICC line care, and failure to investigate an adverse event related to an unwitnessed fall resulting in death. The investigation included interviews with nursing staff, review of medical records, medication administration records, facility policies, and incident reports.

The inspection was conducted due to complaints regarding failure to provide required notifications related to resident transfers, inadequate catheter care leading to urinary tract infections, and improper storage and labeling of medications and biologicals.

The facility failed to provide bed-hold notices, transfer notices, and Ombudsman notifications for residents transferred to hospitals. It also did not ensure appropriate catheter care and monitoring, resulting in urinary tract infections for some residents. Additionally, the facility did not store and label medications and biologicals properly, including expired supplies and unlocked medication refrigerators.

The complaint investigation found that the facility did not provide bed-hold notices, transfer notices, or notify the Ombudsman for residents transferred to hospitals in July and August 2025. It also found inadequate catheter care for three residents, resulting in urinary tract infections, and improper medication storage and labeling.

The inspection was conducted to assess compliance with regulatory requirements related to pharmaceutical services and food safety in the facility.

The facility failed to provide pharmaceutical services that ensured accurate medication administration for two sampled residents, including transcription errors and missed doses. Additionally, the facility did not ensure continued monitoring of food internal temperatures, serving eggs at a temperature below the required standard.

The inspection was conducted to investigate a complaint regarding the facility's failure to notify the physician of laboratory results for resident R7, which led to delayed treatment and hospitalization due to sepsis.

The facility failed to promptly notify the ordering practitioner, Urologist E, or the primary provider about R7's positive urine culture results from 03/23/25. This lack of communication resulted in delayed treatment, and four days later, R7 was hospitalized with sepsis. Interviews confirmed that the lab results were sent to the Medical Director instead of the ordering urologist, and the facility did not update the appropriate providers.

The complaint investigation revealed that the facility did not ensure the physician was notified of laboratory results for resident R7. The urine culture showed significant bacterial growth, but the results were not communicated to the ordering urologist or primary provider, leading to delayed treatment and hospitalization for sepsis.

The inspection was conducted due to a review of the facility-wide assessment and staffing levels following a rapid increase in resident census from the mid-30s to 48 residents.

The facility failed to update its facility-wide assessment to reflect the increased resident census and the corresponding staffing needs. Staff interviews revealed inadequate staffing levels to safely meet resident care needs, resulting in increased workload stress and staff resignations.

The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, infection control, food safety, and other facility operations.

The facility was found deficient in multiple areas including failure to promptly notify physicians of resident condition changes, incomplete PASRR Level II screening, inadequate wound care and pressure injury management, failure to implement a maintenance walking program, improper catheter care, poor food handling and sanitation practices, and lapses in infection prevention and control protocols.

The inspection was conducted due to a complaint investigation regarding an allegation of verbal/emotional abuse by a charge nurse towards a resident during wound care treatment.

The facility failed to timely report a reasonable suspicion of a crime related to verbal abuse and did not thoroughly investigate the allegation of abuse. The charge nurse was suspended and terminated after the incident. The resident reported feeling scared and intimidated. The facility did not involve law enforcement as the resident declined police contact. The investigation lacked interviews with the accused nurse and other staff, and no documented conversations with local law enforcement regarding policy development were found.

The complaint involved a resident (R1) who reported that a charge nurse intimidated him during wound care. The resident recorded the nurse due to feeling scared. The nurse was suspended and terminated. The resident declined police involvement initially but later believed police should be informed. The facility did not report the incident to law enforcement. The investigation was incomplete and lacked thoroughness.

The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations related to resident care, safety, staffing, and facility operations.

The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, inadequate reporting of injuries of unknown origin, failure to provide timely transfer notifications, incomplete PASARR screening, incomplete care plan updates, inadequate supervision and safety measures for residents, failure to monitor resident weight status properly, insufficient RN staffing hours, inaccurate staffing data submission, failure to ensure timely pharmaceutical services, lack of a functional QAPI program, and failure to provide dementia and abuse prevention training to staff.

The inspection was conducted to investigate complaints regarding the facility's failure to ensure resident and family participation in care plan conferences, failure to notify legal representatives of changes in resident conditions, and inadequate treatment and care following resident falls.

The facility failed to notify families and legal representatives about care plan conferences and significant changes in resident conditions, including a resident's transfer to the emergency room and subsequent death. Additionally, the facility did not provide appropriate post-fall assessments and monitoring for residents, nor did it follow physician orders for follow-up care.

The complaint investigation revealed that the facility did not ensure family participation in care plan conferences for residents R2 and R6, failed to notify the legal representative of resident R3's significant change in condition and emergency room transfer, and did not provide adequate post-fall care and follow-up for residents R1 and R2.

The inspection was conducted based on complaints regarding pressure ulcer care, medication regimen reviews, psychotropic medication use, and medication administration errors at Careview Health and Rehab of Minocqua.

The facility failed to evaluate and document pressure injuries weekly for one resident, did not ensure monthly pharmacist medication regimen reviews for multiple residents, failed to implement gradual dose reductions for psychotropic medications despite lack of behaviors justifying their use, and had a medication administration error rate of 7.69% including insulin timing and incorrect medication administration via nebulizer.

The visit was complaint-related focusing on pressure ulcer care, medication regimen reviews, psychotropic medication use, and medication administration errors. Substantiation status is not explicitly stated.