Tomah Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Tomah Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 1, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents with dining for 4 of 40 residents (R28, R38, R17, R290) who require dysphagia diets. Surveyor observed DC I (Dietary Cook) pour ready to serve honey-thickened, lemon flavored, water into pre-poured thin liquids in an attempt thicken the liquids. These liquids were served to R28 and R17. DC I indicated he prepared a total of four residents' (R28, R38, R17 and R290) drinks this way as this is how he was taught. Failure to ensure fluids were served to residents in the appropriate consistency created a finding of Immediate Jeopardy (IJ), which started on 5/18/22. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 5/19/22 at 2:49 PM. […]

• Immediate jeopardy, isolatedF600Aug 10, 2026

  Based on interviews and record review, the facility failed to ensure each resident is free from sexual abuse for 1 of 8 resident's (R8) out of a total sample of 9 residents.R7 had a diagnosis of Sexual Behavior Disorder upon admission. The facility failed to create a baseline care plan with interventions and goals related to this diagnosis. 25 days after admission, staff observed R7 with his hand under R8's lap blanket. Staff did not separate the residents and left them alone to go inform a nurse. No interventions or increased monitoring implemented. The next day, staff observed R7 with his hand under R8's gown and sheet. The facility's failure to ensure residents were free from sexual abuse, created a finding of Immediate Jeopardy (IJ) that began on 7/26/26. […]

• Immediate jeopardy, isolatedF689Dec 22, 2025

  Based on observation, interview, and record review, the facility did not ensure a resident's environment remained as free of accident hazards as possible for 5 of 8 residents (R3, R7, R9, R10, and R11) by failing to have a system in place for monitoring the surface temperature of baseboard heaters to prevent burns. R3 is a resident with impaired mobility and cognition. On 10/29/25, R3 fell out of bed onto the baseboard heater. R3 was stuck between the wall and the bed. R3 sustained partial thickness (2nd Degree) burns. R7 is a resident with impaired mobility, who was observed by Surveyors to have her bed next to the baseboard heater, with the foot of the bed touching the baseboard heater, and the head of the bed less than 6 inches away from the baseboard heater. […]

• Immediate jeopardy, isolatedF812Jun 1, 2022

  Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety to prevent foodborne illness, as the facility served non-pasteurized, runny yolk eggs, to 2 of 3 (R14, R15) supplemental Residents out of a total of 40 residents residing at the facility. Failure to ensure that eggs served were pasteurized or fully cooked placed these residents at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) that started on [DATE]. The facility administrator was made aware of the findings of IJ on [DATE] at 9:54 AM, which was removed on [DATE]. […]

• Immediate jeopardy, isolatedF684Dec 21, 2021

  Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act) to meet each resident's physical needs for 2 of 3 residents reviewed (R1 and R3) out of a total sample of 3 residents. The facility failed to take immediate action to assess, monitor, and evaluate R1's condition and to seek prompt medical intervention to prevent R1's underlying condition from worsening. According to interviews, ED (Emergency Department) and EMS (Emergency Medical Services) notes, this resident had been less responsive in the three-four (,d+[DATE]) days before transfer to the emergency room . […]