Middle River Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Middle River Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF725Aug 31, 2022

  Based on interview and record review, the facility failed to have sufficient nurse staffing to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. This has the potential to affect all 48 residents. *The facility failed to meet staffing requirements, resulting in unlicensed staff working as Med Techs (MT) also known as a Medication Aide (a nursing assistant who has been certified in Wisconsin to pass medications) without a licensed staff member in the building. One of those aides was not certified as a medication aide in the state of Wisconsin. […]

• Immediate jeopardy, widespreadF837Aug 31, 2022

  Based on observation, interview, and record review, the facility Governing Body failed to implement policies related to the management and operation of the facility and were not actively engaged and involved in the daily operations of the facility, which affected the quality of life for all 48 residents. The facility has had frequent turnover of administrative staff over the past 8 months and is currently without an administrator in the building. The facility has had 5 different Directors of Nursing (DON) since February of this year, and the current DON is unable to fulfill the DON duties due to working to cover nursing shifts on the floor. The facility has had chronic problems with inadequate staffing and supplies over the past few months. […]

• Immediate jeopardy, patternF678Aug 31, 2022

  Based on interview and record review, the facility did not ensure that facility staff is able to provide emergency basic life support immediately when needed, including Cardiopulmonary Resuscitation (CPR,) to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 14 of 48 residents (R) in the facility (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). The facility did not have licensed staff available on nine shifts, from [DATE] through [DATE], who could immediately initiate CPR should any of the 14 residents who desired CPR have a cardiopulmonary arrest. […]

• Actual harm, isolatedF689Feb 3, 2026

  Based on observation, interview, and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received adequate supervision and assistance devices to prevent accidents.Certified Nursing Assistant (CNA) C did not use stand aid correctly causing a fall resulting in R1 sustaining a fracture.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15, which indicates severe cognitive impairment.Care plan includes in part: a focus of self-care deficit related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility with interventions of high fall risk last revised on 11/22/25. Transfers: stand aid assist of 1. […]

• Actual harm, isolatedF770Sep 20, 2022

  Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 Residents (R) reviewed, Resident R8. The facility was not monitoring Nurse Practitioner (NP) F's notes requesting lab orders. Lab collections were not obtained timely resulting in a resident being hospitalized and treated with intravenous antibiotics for a urinary tract infection ([CONDITION(S)]) eleven days after NP F requested a urinalysis due to R8 exhibiting symptoms of a [CONDITION(S)]. This is evidenced by: R8 admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/20/22, at 9:35 AM, Surveyor interviewed Nurse Practitioner (NP) F about resident appointments. […]