Beaver Dam Health Care Center

In the surveyor’s words

From the most serious findings on record at Beaver Dam Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 18, 2026

  Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents/hazards with smoking material. Staff observed R3 to be smoking while using oxygen in his room this had the potential to affect R3 and 12 of 12 residents (R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) who reside on the 100 hall. R4 was observed not to have smoking material secured, R4 handed a cigarette lighter to R5 in the hallway. […]

• Immediate jeopardy, isolatedF689Mar 18, 2026

  Based on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents and hazards for 1 of 3 residents (R1) reviewed for safety.On 2/27/26, a resident (R1) who smokes started a fire in her room using a lighter that she was deemed safe to have in her possession. R1 was not reassessed for safety after igniting material in her room and continued to have smoking materials in her possession without safety interventions being put in place to ensure she does not start another fire within the building. […]

• Immediate jeopardy, isolatedF686Jun 25, 2024

  Based on observation, interview, and record review, the facility did not ensure that a resident with a pressure injury received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new injuries from developing for 6 of 6 residents (R3, R2, R5, R8, R9, and R10) with pressure injuries or at risk for developing pressure injuries. R3 admitted to the facility with a stage IV pressure injury to her sacrum that worsened. R3 developed six other pressure injuries while in the facility, all identified as a stage III or unstageable. R3 did not have treatments done for her wounds on all dates and times as ordered. R3 had two wound care orders that were not completed. […]

• Immediate jeopardy, isolatedF684Jan 29, 2024

  Based on interview and record review, the facility failed to provide care consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act) by failing to monitor a resident while the resident was experiencing a change in condition despite an order from the primary physician to monitor for 1 (R2) of 3 residents reviewed for change in condition out of a total sample of 12 residents. R2 experienced a change in condition on [DATE]. The facility failed to complete ongoing assessments of the resident's condition. R2 continued to decline throughout the day; the facility did not update the physician or complete thorough assessments of resident's condition. […]

• Immediate jeopardy, isolatedF686Jan 29, 2024

  Based on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 3 residents (R4) reviewed for PIs out of a sample of 12 residents. R4 was admitted to the facility without a PI. R4 was at risk for PI development and had significant co-morbidities including diabetes and right ankle fracture requiring a sugar-tong splint (rigid device that fixes and maintains stability of the ankle). An external fixator was placed on 3/10/23 to the right lower extremity. […]