Inspection Reports for Nu-Roc Health and Rehabilitation Center
3576 Nu Roc Lane, Laona, WI 54541, Laona, WI, 54541
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASARR screening, resident safety, medication administration, food safety, staffing data accuracy, and infection control.
Findings
The facility was found deficient in multiple areas including failure to complete accurate PASARR Level II screening, inadequate supervision and accident hazard prevention, medication administration errors, unsafe food storage and preparation practices, inaccurate staffing data submission to CMS, and failure to maintain infection prevention protocols.
Deficiencies (6)
Failure to ensure a PASARR Level II Screen was completed for one resident due to inaccurate Level I screening.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision for two residents.
Failure to provide safe administration of drugs and biologicals for two residents, including incorrect aspirin form and incorrect placement of lidocaine patch.
Failure to ensure food was stored and prepared in a safe and sanitary manner, including lack of food cooling logs, untested sanitizing solution, inadequate warewashing temperatures, and undated/expired food items.
Failure to electronically submit accurate mandatory staffing information based on payroll data to CMS.
Failure to maintain an infection prevention and control program, including failure to wear gown during medication administration via PEG tube for one resident.
Report Facts
Residents sampled: 14
Residents sampled: 6
Residents sampled: 3
Dish Machine Log PPM entries out of range: 27
Dish Machine Log PPM entries out of range: 27
Dish Machine Log wash cycles out of range: 5
Dish Machine Log rinse cycles out of range: 6
Dish Machine Log wash cycles out of range: 10
Dish Machine Log rinse cycles out of range: 11
PBJ staffing quarter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW-F | Social Worker | Interviewed regarding PASARR screening compliance and resubmission of PASARR Level I Screen |
| DON-B | Director of Nursing | Verified oxygen concentrator use, medication administration errors, resident transfer supervision, and infection control gown use |
| MD-G | Maintenance Director | Observed encouraging resident transfer and warewashing machine temperature issues |
| LPN-I | Licensed Practical Nurse | Observed administering incorrect medications and improper lidocaine patch placement, and failure to wear gown during PEG tube medication |
| CNA-J | Certified Nursing Assistant | Confirmed oxygen concentrator should be turned off when resident not in room |
| CNA-H | Certified Nursing Assistant | Indicated resident transfer requirements |
| DM-D | Dietary Manager | Interviewed regarding food safety, sanitizing solution testing, warewashing issues, and undated/expired food |
| DA-K | Dietary Aide | Confirmed sanitizing solution not tested and warewasher sanitizer setting incorrect |
| BOM-E | Business Office Manager | Provided staffing timecard data and discussed PBJ submission issues |
| DOO-C | Director of Operations | Discussed PBJ submission errors and staffing data resubmission |
| CK-L | Cook | Observed warewashing machine use and discussed temperature issues |
Inspection Report
Routine
Census: 37
Deficiencies: 3
Date: May 15, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including trauma-informed care, staffing data accuracy, and infection prevention and control.
Findings
The facility failed to ensure a culturally competent, trauma-informed care plan for one resident with a trauma history, submitted inaccurate Payroll Based Journal staffing data for two quarters, and did not sanitize mechanical lifts between residents, posing infection control risks.
Deficiencies (3)
Failed to create a culturally competent, trauma-informed care plan for 1 of 1 resident with trauma history.
Failed to submit accurate Payroll Based Journal staffing data for Q4 2023 and Q1 2024 affecting all 37 residents.
Failed to sanitize mechanical lifts between residents, risking transmission of infections for 2 of 6 residents using lifts.
Report Facts
Residents affected: 1
Residents affected: 37
Residents affected: 2
Days after incident: 129
Date of survey: May 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding staffing triggers and behavioral health referral for resident R19 |
| Director of Nursing B | Director of Nursing | Informed police about smoking incident and interviewed regarding sanitizing mechanical lifts |
| Social Worker H | Social Worker | Interviewed about resident R19's care plan and trauma triggers |
| Corporate Payroll Staff G | Corporate Payroll Staff | Interviewed about payroll software switch affecting staffing data |
| Business Office Manager F | Business Office Manager | Interviewed about staffing data entry issues and corrections |
| Certified Nursing Assistant C | Certified Nursing Assistant | Observed failing to sanitize mechanical lift after resident transfer |
| Certified Nursing Assistant D | Certified Nursing Assistant | Interviewed about lift sanitization practices and observed failing to sanitize lift |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure the right to privacy for Resident 7 (R7) during personal care.
Complaint Details
The complaint investigation found that Resident 7's privacy was compromised due to the facility's policy requiring the door to remain open during personal care under 1:1 supervision. Resident 7 expressed feeling furious about the lack of privacy. The Nursing Home Administrator confirmed the policy and the reasons behind it, including safety concerns related to a shared bathroom and preventing wandering.
Findings
The facility required R7's door to remain open during personal care due to 1:1 supervision requirements, which violated R7's right to privacy. Staff did not offer to close the privacy curtain, and the door remained open despite R7's expressed desire for privacy. The facility cited safety concerns related to a shared bathroom and potential wandering as reasons for keeping the door open.
Deficiencies (1)
Facility did not ensure the right to privacy for Resident 7 during personal care as the door was required to remain open and staff did not offer to close the privacy curtain.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding the facility's policy on keeping Resident 7's door open during personal care and supervision. |
| Social Worker (SW)-C | Social Worker | Interviewed about 1:1 supervision requirements and the policy of keeping Resident 7's door open. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a physician of an abnormal lab value for one resident related to medication monitoring.
Complaint Details
The visit was complaint-related due to failure to notify a physician of an abnormal lab value. The deficiency was substantiated as the facility did not obtain or report the high Keppra level to the physician.
Findings
The facility did not notify the physician of a high Keppra level (80 ug/mL) in Resident 1's blood, which was above the therapeutic range. The Director of Nursing confirmed the facility did not obtain or report the lab results prior to the surveyor's request.
Deficiencies (1)
Failure to notify a physician of an abnormal lab value for one resident related to medication monitoring.
Report Facts
Keppra level: 80
Residents reviewed for medication monitoring: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Verified the facility did not obtain or report the abnormal lab results prior to surveyor's request |
| RN-C | Registered Nurse | Informed surveyor that lab results were not contained in resident's medical record |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication consent, PASRR screening, care planning, food safety, and rehabilitative services at Nu Roc Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure protective placement petitions, lack of informed consent for psychotropic medications, incomplete PASRR screening, inadequate comprehensive care plans for residents, unsafe food handling practices including lack of temperature monitoring and expired sanitizer test strips, and delayed speech therapy services for a resident.
Deficiencies (6)
Failure to ensure a petition for protective placement was made for one resident whose nursing home stay exceeded 60 days without active discharge planning.
Failure to obtain written consent from residents or their legal representatives for prescribed psychotropic medications for 3 residents.
Failure to complete PASRR Level I screening and referral for one resident with mental illness diagnoses receiving psychotropic medication.
Failure to develop comprehensive, person-centered care plans for 4 residents addressing medication monitoring, chronic conditions, fall risk, and other needs.
Failure to ensure safe food handling practices including lack of cooling temperature monitoring, missed holding temperature logs, and expired sanitizer test strips.
Failure to provide timely speech therapy services including delayed evaluation and lack of swallow study for one resident.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents sampled for PASRR screening: 5
Residents sampled for care plan review: 13
Residents affected by food safety deficiencies: 36
Fall risk score: 9
Medication doses: 5
Medication doses: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker (SW)-D | Social Worker | Interviewed regarding protective placement paperwork for resident R28 |
| Interim Director of Nursing (DON)-B | Interim Director of Nursing | Interviewed regarding informed consents for medications and care plan issues |
| Medical Records Clerk (MR)-C | Medical Records Clerk | Confirmed lack of medication consents for resident R1 |
| Dietary Manager (DM)-F | Interim Dietary Manager | Interviewed regarding food temperature logs and sanitizing solution testing |
| Registered Dietician (RD)-G | Registered Dietician | Confirmed food safety deficiencies and sanitizing solution testing issues |
| Speech Therapist (ST)-E | Speech Therapist | Provided speech therapy via Telehealth for resident R12 |
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding delays in speech therapy and swallow study for resident R12 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an allegation of sexual abuse involving two residents and failure to revise a care plan accordingly.
Complaint Details
The complaint involved an allegation of non-consensual sexual abuse/assault by Resident 3 (R3) against Resident 2 (R2) on 1/21/23. The facility did not report the allegation to law enforcement. The Nursing Home Administrator verified the incident was considered sexual assault and a crime, and that law enforcement should have been contacted but was not.
Findings
The facility failed to report an allegation of sexual abuse/assault involving two residents to law enforcement as required by the Elder Justice Act. Additionally, the facility did not revise the care plan for one resident involved in the incident to address the concerns. The facility also failed to provide appropriate pressure ulcer care for another resident by not consistently applying pressure-relieving boots while in bed.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to develop and revise the complete care plan within 7 days of the comprehensive assessment for a resident involved in sexual abuse allegations.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing by not applying pressure-relieving boots consistently.
Report Facts
Residents sampled: 5
BIMS score: 11
BIMS score: 1
Care plan revision timeframe: 7
Hours without pressure-relieving boots: 3
Staff assistance: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Verified the nonconsensual touch was sexual assault and a crime, and that law enforcement was not contacted but should have been. | |
| Director of Nursing (DON)-B | Verified pressure-relieving boots were to be worn at all times in bed and that declinations should be documented. | |
| Certified Nursing Assistant (CNA)-C | Observed transferring R1 and verified heel boots were to be applied whenever R1 was in bed. |
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