Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barron Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, moderately impaired cognition, and documented wandering and elopement risk had a care plan that included one-on-one supervision, structured activities, and a wander guard device. On one occasion, the wander guard alarm sounded as the resident exited the building, but staff did not respond promptly, and the resident was found outside the front entrance in a wheelchair. Although the incident involved potential neglect due to lack of supervision, the DON initially decided it was not reportable, and the administrator did not submit the required abuse/neglect report to the State Survey Agency within the mandated timeframe or complete the misconduct incident report within five business days, resulting in delayed reporting of the alleged violation.
A resident with severe dementia, dependence in all ADLs, and documented BUE ROM issues developed bruising to the left arm and breast and was later found in the ER to have an anterior left shoulder dislocation. Staff reported no falls or equipment malfunctions, and the RN initially noted only a small bruise and was unsure if he fully documented its size and location. Nursing weekly assessments repeatedly documented no contractures, while therapy records showed significant upper extremity contractures and spasticity affecting dressing and bathing. The DON told police and surveyors that the facility could not determine how the injury occurred, yet the facility assumed it was related to improper upper body dressing technique despite lacking documentation of upper extremity contractures and including only a vague disciplinary form for a CNA who had transferred the resident alone with a Hoyer lift.
Two residents in a LTC facility developed or worsened pressure injuries due to inadequate care and documentation. One resident, initially admitted without skin impairments, developed a stage 3 pressure injury that progressed to stage 4 due to insufficient assessments and interventions. Another resident had multiple pressure injuries upon admission, but the facility failed to document them accurately or implement consistent repositioning as per the care plan. The interim DON acknowledged the deficiencies and initiated a facility-wide skin sweep and PIP.
The facility failed to provide written notification of transfer or discharge reasons to residents or their legal representatives for five residents. Despite the facility's policy requiring such notices, interviews and record reviews revealed that no written notices were given for transfers to hospitals due to medical conditions. Staff interviews indicated confusion over responsibility for issuing these notices.
The facility failed to provide written bed hold notices to residents or their representatives during transfers to hospitals, affecting five residents. Despite policy requirements, no notices were given, and staff interviews revealed confusion over responsibility for issuing these notices.
Surveyors observed CNAs using clothing protectors to wipe residents' mouths instead of napkins during meal assistance, affecting three residents with cognitive impairments and physical limitations. Despite the availability of napkins, this practice continued, contradicting the facility's policy on maintaining resident dignity.
A resident with multiple health issues, including cognitive impairment and total dependency on staff, was repeatedly observed without access to a call light, preventing them from requesting assistance. Despite the resident's visible discomfort and attempts to call for help, staff failed to ensure the call light was within reach, contrary to facility expectations.
The facility failed to develop comprehensive care plans for two residents, one with hemiplegia and another with severe cognitive impairment, leading to deficiencies in maintaining their baseline ADLs. The care plans lacked necessary updates and interventions, such as a restorative range of motion program and addressing personal preferences for ADL assistance.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple medical conditions had a fall intervention not included in their care plan, and their incontinence care plan was not updated after a change in mobility status. Another resident with moderate cognitive impairment and total dependence for ADLs had an outdated care plan that did not reflect their current needs, including the use of a Hoyer lift for transfers.
A resident with severe cognitive impairment and incontinence was not provided necessary toileting and hygiene care. Observations showed the resident was left in a chair for extended periods without being taken for incontinence care, and staff confirmed the resident was only toileted in the morning. The Interim DON acknowledged the need for toileting before and after meals.
A resident with hemiplegia and hemiparesis following a stroke did not receive the recommended restorative range of motion program after being discharged from PT and OT. Despite recommendations, the program was not implemented, leading to a decline in mobility and ADL functions. Staff interviews revealed a lack of awareness and implementation of the program, and the restorative program book did not include the resident's information.
A facility failed to ensure proper labeling of insulin pen medications, leading to a discrepancy between the label and the physician's order for a resident with diabetes mellitus II. The insulin pen was labeled with a fixed dose, while the order required a sliding scale dosage. The RN confirmed the error, and the DON acknowledged that the facility's policy for verifying medication labels was not followed, as the error was not corrected upon receipt, nor was the pharmacy notified.
The facility failed to maintain proper infection control practices as CNAs did not perform hand hygiene between glove changes while providing care to two residents. Despite the facility's policy requiring hand hygiene before and after glove use, CNAs were observed neglecting this practice during morning and catheter care, compromising infection prevention efforts.
Failure to Timely Report Elopement and Potential Neglect Incident
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving potential neglect related to a resident elopement, as required by regulation and facility policy. A resident with dementia and moderately impaired cognition, confirmed by a BIMS score of 8/15, had documented wandering behaviors and was assessed as being at significant risk of getting to a potentially dangerous place. The resident’s care plan identified them as an elopement risk with a history of wandering and exit-seeking behaviors and impaired safety awareness, and included interventions such as one-on-one supervision, structured and meaningful activities, and use of a wander guard device on the left wrist with checks for placement every shift and function checks daily. On the date of the incident, the resident’s wander guard alarm activated when the resident exited the building, but staff did not respond to the alarm in a timely manner. The facility’s own elopement policy stated that alarms are not a replacement for necessary supervision and that staff are to be vigilant in responding to alarms promptly, and that adequate supervision will be provided to help prevent accidents or elopements. A CNA later reported hearing the alarm but stated the alarms are hard to hear and that she responded as soon as she could; by the time she responded, the resident had already eloped from the building and was found outside the front doors on the sidewalk, sitting in a wheelchair and stating they were getting some fresh air. The resident was brought back inside and had no injuries, and staff reported the incident to the DON. Despite the elopement and the resident’s known elopement risk, the DON reviewed the elopement policy on the day of the incident and initially determined the event was not reportable because the resident did not leave the property. The incident was not reported to the State Survey Agency within two hours, even though it involved potential neglect related to lack of supervision. The administrator later determined the incident was reportable due to lack of supervision and submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report the following day, outside the required timeframe. In addition, the misconduct incident report required within five business days of discovery was not successfully submitted within that timeframe, and the administrator did not use the available email system when experiencing difficulty with the electronic reporting system, resulting in further delay in required reporting.
Failure to Thoroughly Investigate Injury of Unknown Origin and Inconsistent Documentation of Contractures
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an injury of unknown origin for one resident with severe cognitive impairment and extensive physical limitations. The resident had vascular dementia with anxiety, Alzheimer’s disease, fibromyalgia, weakness, and multiple lower extremity contractures, and was dependent for all ADLs with transfers requiring a Hoyer lift and two-person assist. The care plan did not specify sling size for Hoyer transfers. The most recent MDS indicated the resident was rarely/never understood and had upper and lower extremity ROM impairments, while multiple weekly nursing skin/condition assessments documented no contractures present. Therapy records, however, showed the resident had significant BUE contracture and ROM issues that affected bathing and dressing, with documented spasticity and tone differences. On the date of the incident, nursing staff were notified of bruising on the resident’s left arm and left breast, along with pallor and poor oral intake. The RN assessed what he described as a small bruise on the back of the arm, reported it to the DON, and was instructed to monitor for worsening, but he was unsure if he documented the size and exact location. The CNA on duty that morning reported she did not look at the resident’s upper body, did not observe bruising, and only reported that the resident appeared different and pale. There were no reports of falls or equipment malfunction, and staff interviews did not identify a clear cause of injury. Subsequent evaluation in the ER identified an anterior left shoulder dislocation with associated ecchymosis, and the ER physician expressed concern for possible abuse or neglect given the resident’s non-ambulatory status and lack of reported falls. During the facility’s internal review, the DON stated that the facility could not determine how the resident sustained the dislocated shoulder and bruising and acknowledged there was no documented explanation for the injury. The DON reported that the facility ultimately assumed the cause was improper upper body dressing technique related to contractures, based on the ER note suggesting this as a possibility and the absence of reported falls or equipment misuse. However, the DON was unable to produce nursing documentation supporting the presence of upper extremity contractures prior to the incident and was unaware that nursing assessments repeatedly documented no contractures. A disciplinary form for a CNA who admitted to transferring the resident alone with a Hoyer lift, despite a two-person requirement, was included in the investigation file, but the form did not identify the resident or provide details of the event. The police report documented that the DON told law enforcement the facility was not able to figure out how the resident obtained the dislocation and bruising, and no further information from external agencies was available in the facility’s investigation file.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development and worsening of pressure injuries. Resident R29 was admitted without skin impairments but developed a stage 3 pressure injury to the coccyx, which progressed to a stage 4 due to insufficient comprehensive assessments, delayed care plan interventions, and inadequate repositioning. The facility's documentation was inconsistent, with errors in wound staging and a lack of timely updates to care plans and treatment orders. Despite being identified as high risk for pressure injuries, R29's care plan did not include necessary interventions such as pressure-reducing devices or a repositioning program until much later. Resident R18 was admitted with multiple pressure injuries, but the facility failed to document their locations, sizes, or stages accurately. The care plan for R18 included repositioning every 1-2 hours and specific post-meal positioning, but these interventions were not consistently implemented. Observations revealed that R18 was often left in the same position for extended periods, contrary to the care plan instructions. The facility's documentation of R18's pressure injuries was unclear and contradictory, with no new interventions implemented despite the presence of multiple pressure injuries. The facility's interim Director of Nursing (DON) acknowledged the deficiencies in wound care and documentation, noting that wound assessments were not being recorded accurately and were scattered across different sections of the electronic health record. The interim DON initiated a facility-wide skin sweep and a Performance Improvement Plan (PIP) in response to the identified issues. However, the report focuses on the facility's failure to prevent the development and worsening of pressure injuries for residents R29 and R18, highlighting significant lapses in care and documentation.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification to residents or their legal representatives regarding the reasons for transfer or discharge for five out of six residents reviewed. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy mandates that before a resident is transferred or discharged, the resident and their representative must be notified in writing of the reasons, proposed date, and location of the transfer. However, in the cases of residents R10, R14, R25, R8, and R15, no such written notices were provided. For instance, R10 was transferred to the emergency department for medical reasons, but no notice was given to their legal representative. Similarly, R14, who had severe cognitive impairment, was transferred multiple times without written notification to their representative. Other residents, such as R25, R8, and R15, were also transferred to hospitals due to medical conditions, yet their records lacked the required written notices. Interviews with the Interim Director of Nursing and Social Services staff revealed a lack of clarity and responsibility regarding the issuance of these notices, contributing to the deficiency.
Failure to Provide Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during facility-initiated transfers to hospitals or therapeutic leaves. This deficiency was identified for five out of six residents reviewed for hospitalization. The facility's policy requires that residents receive written information about the state's bed hold duration and payment amount before transfer, but this was not adhered to in multiple cases. For instance, one resident was transferred to the emergency department for right lower quadrant pain, and no bed hold notice was given to their legal representative. Another resident with severe cognitive impairment was transferred multiple times to the emergency room, yet no written bed hold notice was documented or provided to their legal representative. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of bed hold notices. The Interim Director of Nursing (DON) and Social Services (SS) staff indicated confusion over who was responsible for providing these notices. The previous DON was reportedly handling the notices, but the current staff had not continued this practice. This oversight resulted in the failure to provide necessary documentation to residents or their representatives, as evidenced by the absence of bed hold notices in the medical records of several residents who were transferred to hospitals.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal assistance, as observed by surveyors. Certified Nursing Assistants (CNAs) were seen using residents' clothing protectors to wipe their mouths instead of using the provided napkins. This practice was observed with three residents, each with varying degrees of cognitive impairment and physical limitations, who required assistance with eating. Despite the availability of napkins, CNAs continued to use clothing protectors, which is not in line with the facility's policy on maintaining residents' dignity. Resident 13, who has severe cognitive impairment and is dependent on staff for meal assistance, was observed being assisted with a pureed meal by CNA I, who used the clothing protector to clean the resident's mouth. Similarly, Resident 18, with moderate cognitive impairment and total dependence for eating, was assisted by CNA E, who also used the clothing protector instead of a napkin. Resident 17, with moderate cognitive impairment and physical limitations, expressed dissatisfaction with the use of the clothing protector for wiping their face, preferring a napkin or tissue. The Interim Director of Nursing confirmed that staff should be using napkins, not clothing protectors, for this purpose.
Resident Lacks Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, had access to a call light, which is necessary for requesting assistance. R18, who was admitted with multiple diagnoses including vascular dementia, hemiplegia, and pressure ulcers, was observed multiple times without the call light within reach. Despite R18's moderate cognitive impairment and total dependency on staff for mobility and other activities, the call light was consistently found draped underneath the pillow or out of reach, preventing R18 from effectively communicating needs to the staff. Throughout the observations, R18 was noted to be yelling for assistance, indicating discomfort and a need for help, yet the call light remained inaccessible. Staff members, including CNAs and an LPN, were informed of R18's needs but did not ensure the call light was placed within reach. The Interim Director of Nursing acknowledged that the expectation is for all residents to have call lights within reach, but this was not adhered to in R18's case, as confirmed by a CNA who admitted to being unaware of the call light's inaccessibility due to being busy.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in maintaining their baseline Activities of Daily Living (ADLs). For one resident, who was admitted with conditions including hemiplegia and hemiparesis following a stroke, the facility did not incorporate a restorative range of motion program into the care plan, despite recommendations from physical therapy. This resident expressed concerns about not receiving appropriate services to maintain some independence, resulting in total reliance on staff for all care. The Interim Director of Nursing was unaware of the physical therapy recommendation and acknowledged the absence of a restorative care plan. Another resident, with severe cognitive impairment and multiple medical conditions, did not have a care plan addressing personal preferences and dependency on staff for assistance with ADLs such as showering, dressing, oral care, and bed mobility. The surveyor noted that the comprehensive care plans for this resident were not up to date, and the Interim Director of Nursing confirmed the understanding that the care plans were lacking necessary updates.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans for two residents, leading to deficiencies in their care. Resident 14, who has severe cognitive impairment and multiple medical conditions including repeated falls and incontinence, experienced a fall on June 13, 2024. Although a new intervention of a fidget blanket was introduced to decrease anxiety, this was not included in the resident's comprehensive care plan for falls. Additionally, after being hospitalized and returning with a non-weightbearing status, the resident's bladder incontinence care plan was not updated to reflect the new condition, as it still indicated the resident should request assistance with ambulation to the bathroom. The Interim Director of Nursing acknowledged that the care plans were not up to date. Resident 17, with moderate cognitive impairment and requiring total dependent assistance for activities of daily living (ADLs), had an outdated ADL care plan. Despite the resident's need for total assistance and use of a Hoyer lift for transfers, the care plan still stated that the resident could transfer with an EZ stand and participate in dressing tasks. This discrepancy was observed during a survey, and the Interim Director of Nursing was unaware of the outdated care plan, indicating a lack of awareness of the resident's current ADL needs.
Failure to Provide Toileting and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for toileting and personal hygiene to a resident, identified as R14, who was unable to carry out activities of daily living independently. R14 had a range of medical conditions, including severe cognitive impairment, muscle weakness, and incontinence, which required staff assistance for transfers, toileting hygiene, and other personal care activities. Despite these needs, observations revealed that R14 was left sitting in a Broda chair by the nurse's station for extended periods without being taken for incontinence care or being asked if they needed to use the bathroom. On the day of observation, R14 was seen being moved to the dining room for meals but was not provided with toileting care before or after meals, as confirmed by interviews with staff. A Certified Nursing Assistant (CNA) indicated that R14 was last toileted in the morning and would only be taken to the bathroom upon request, despite R14's severe cognitive impairment. The Interim Director of Nursing acknowledged that residents should be toileted before and after meals, indicating a lapse in the facility's adherence to care protocols for dependent residents.
Failure to Implement Restorative Care Program for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their condition. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was discharged from physical and occupational therapy with a recommendation for a restorative range of motion program. However, this program was never implemented, leading to a decline in the resident's mobility and activities of daily living (ADL) functions. The resident expressed feeling totally reliant on staff for care, indicating a lack of independence that could have been mitigated with proper restorative care. During the survey, it was observed that no restorative care was provided to the resident over a three-day period. Interviews with staff, including CNAs and the Interim Director of Nursing, revealed a lack of awareness and implementation of the recommended restorative program. The restorative program book, which should have contained the resident's program, did not include any information for the resident, and staff were not completing the necessary exercises. This oversight resulted in the resident not receiving the care needed to maintain or improve their range of motion, as recommended by therapy professionals.
Medication Labeling Deficiency for Insulin Pen
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically concerning the labeling of insulin pen medications. During a medication administration observation, a surveyor noted that an insulin pen for a resident with diabetes mellitus II was labeled incorrectly. The label on the insulin pen indicated a fixed dose of 7 units to be administered before lunch, which did not match the physician's order for a sliding scale dosage based on blood sugar levels. The discrepancy was confirmed by the RN administering the medication, who acknowledged that the pharmacy had been sending insulin pens with incorrect labels following a change in the order. The Director of Nursing (DON) confirmed that the facility's policy required verification of medication labels upon receipt from the pharmacy and during administration. The DON stated that any discrepancies should be corrected by applying a sticker to verify the order with the Medication Administration Record (MAR) before administration. However, in this case, the error was not corrected when the insulin pen was first received, and no evidence was provided that the pharmacy had been notified of the labeling error. This oversight had the potential to harm the resident involved.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not performing proper hand hygiene during care procedures for two residents. The facility's policy on hand hygiene, dated 02/02/24, clearly states that hand hygiene must be performed before donning gloves and immediately after removing them. However, during observations, Certified Nursing Assistants (CNAs) D and E did not adhere to this policy while providing morning and catheter care for residents R2 and R29. For instance, CNA D was observed changing gloves multiple times without washing hands or using hand sanitizer while providing care to R2, who was on enhanced barrier precautions due to an indwelling Foley catheter. Similarly, during care for R29, CNA E also failed to perform hand hygiene between glove changes. Despite using hand sanitizer and donning gloves before entering the room, CNA E did not wash hands or use hand sanitizer after removing gloves during perineal care and other procedures. These actions were contrary to the facility's infection control practices and policies. The Interim Director of Nursing acknowledged the observations and confirmed that the CNAs did not follow the required infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Barron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - Rice Lake | 8.4 mi | — | 1 | 0 |
| Heritage Lakeside | 9.2 mi | — | 15 | 1 |
| Meadowbrook At Chetek | 11.4 mi | — | 5 | 0 |
| Care And Rehab - Cumberland | 12.2 mi | — | 14 | 0 |
| Golden Age Manor | 26 mi | — | 2 | 0 |
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