Meadowbrook at Black River Falls

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment and food was not properly stored with the potential to affect 36 of the 39 residents in the facility as 3 of the residents received tube feeding. Surveyor observed staff taking a dirty plate from the dining room back to the hot food service and placing more food on the dirty plate. Surveyor observed food items stored less than 6 inches from the floor.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 39 residents (R),Staff transported clean laundry from laundry area through the facility to resident rooms without covering the clean clothing which could lead to contamination of clean laundry. Staff did not perform appropriate hand hygiene and glove use during tube feeding administration for R17. This affected 1 out of 3 sampled residents for tube feeding. Staff performed medication pass on two separate residents on contact precautions but did not put on personal protective equipment (PPE) (R9, R12). Staff did not perform hand hygiene before glove use when administering eye drops to R9. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 5 residents (R)(R2, R8, R3, and R4) reviewed for receiving a psychotropic medication were free from unnecessary drugs. R2 was prescribed Quetiapine (Seroquel), an antipsychotic, without adequate indication or diagnosis. R8 was administered diphenhydramine-APAP (Benadryl/Tylenol) on a routine basis for sleep without adequate indication. R8 was administered lorazepam, an anti-anxiety medication, without adequate indication. R3 was prescribed Sertraline, an antidepressant, and Risperidone, an antipsychotic, without appropriate indication from a psychiatric provider. R4 was prescribed Cymbalta, an antidepressant, without adequate indication or diagnosis. This is evidenced by: Facility policy titled, Psychotropic Management, with a revised date of 12/2025, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R)(R42, R4, R31, and R44) received a written notice of transfer to include reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman and did not notify Ombudsman of transfer/discharge. In addition, the facility did not ensure residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. This affects 4 of 4 residents reviewed for transfers and hospitalization. R42 was transferred to the hospital on [DATE] and 11/19/25. No written notice of transfer or Ombudsman notification for either date. No bed hold notice for transfer out on 11/18/25. R4 was transferred to the hospital on 8/11/25 and 9/2/25. [...]

Inspectors wroteBased on interview and record review, facility did not ensure pharmacy recommendation reports were acknowledged by a physician for 3 of 5 residents (R) (R8, R3, and R4) reviewed. R8 had pharmacy recommendations to review medications for contributing to recent falls and the provider did not respond. R3 had pharmacy recommendations to attempt a gradual dose reduction (GDR) of psychotropic medications and the provider did not respond. R4 had pharmacy recommendations to attempt a gradual dose reduction of a psychotropic medication and the provider did not responsd. This is evidenced by: Facility policy titled, Medication Regimen Review, with a revised date of 01/2026, states in part: Procedure: 1. [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R3, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 1 resident (R)(R3) reviewed. This is evidenced by:According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual/developmental disability (ID/DD) and/or mental illness. This is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or mental illness. [...]

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to provide the necessary care to ensure residents' activities of daily living (ADLs) needs were met, which affected 1 (Resident #2) of 3 residents reviewed for ADLs. Specifically, the facility did not transfer Resident #2 out of bed for several hours due to the slings for the mechanical lift used to transfer the resident being unavailable.

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 1 of 1 resident (R5) reviewed for SUDs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not provide anticoagulation therapy for 2 of 3 residents (R) (R1 and R8) reviewed. -Facility failed to verify and transcribe new physician orders with increased Warfarin dose which resulted in R1 not receiving the correct Warfarin dose. This resulted in R1 being sent to the Emergency Department (ED) needing an intravenous (IV) drip of heparin for adequate warfarin anticoagulation, and lovenox bridging until the international normalized ratio (INR) was back in therapeutic range. This example is cited at actual harm. -Facility failed to verify and transcribe R8's new physician orders with increased Warfarin dose changes.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure medications were administered in a safe and effective manner for 1 out of 6 residents (R2). RN set down Resident (R) 2's medications on tray table and left the room. There is a Self-Administration Assessment by the facility stating R2 is incapable of self-administering medications. When RN came back to the room resident had to tell her she took medications already when RN attempted to administer. This is evidenced by: The facility policy, titled Self-Administration of Medications dated May 2020, states: Each resident as the right to self-administer medication if he or she can do so. 2. If a resident desire to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate by completing a Medication Self Administration Assessment UDA. 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure medications were stored securely and in accordance with currently accepted professional practice. The medication cart was left unlocked in 1 out of 2 medication carts. This is evidenced by: The facility policy, titled Medication Storage dated January 2023, states: It is the policy of this facility to ensure all medications housed on our premised will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure . security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, . On 01/22/25 at 10:03 AM, Surveyor observed an unattended medication cart unlocked outside R5's room on 300 hall. [...]

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 31 residents residing in the facility. The facility's Dietary Manager (DM) is currently enrolled but has not started classes to be a Certified Dietary Manager. The Dietary Manager has been in the position for approximately two weeks. The facility does not have a full-time Registered Dietician at the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment. This has the potential to affect all 31 residents in the facility. Staff did not consistently date or label food items when opened. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution. Staff did not consistently document refrigerator and freezer temperatures. Staff did not consistently test or document dish machine temperatures. Staff observed touching ready to eat food with contaminated gloves. Staff observed delivering trays to resident rooms with uncovered food items on the tray.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not follow proper personal protective equipment (PPE) procedures when doing wound care for a resident (R) on enhanced barrier precautions (EBP) and did not sanitize bandage scissors and marking pen prior to and after use. This affected 1 of 2 residents (R) observed for wound care. (R3)

Inspectors wroteBased on observations and interview, the facility did not ensure the daily nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 31 residents in the building. The facility's nurse staffing sheets were not posted daily. Evidenced by: According to federal regulations, the facility must post the nurse staffing data on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents and visitors. On 12/17/24, Surveyor was not able to locate the daily nurse staffing posting. At 12:22 PM, Surveyor asked Nursing Home Administrator (NHA) A where to find the daily staffing posting. NHA A stated it was their second day on the job and they did not know where it was located but would find out. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (R187) reviewed for accidents. R187 had an elopement from the hospital prior to admission and, following admission here, eloped from the building on 3 separate occasions. On the second elopement, R187 was missing for 2.5 hours, which required police and a K9 search to find R187. On the third elopement, R187 traveled 1.4 miles to a bridge, running through busy traffic, and attempted to jump off the bridge. Facility failure to provide adequate supervision created a finding of immediate jeopardy that began on 08/23/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/09/24 at 1:00 PM. The immediate jeopardy was removed on 08/26/24 and corrected on 08/27/24. This is being cited as past noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. Milk and juice, placed in the walk-in-cooler, had been opened but were not labeled with an opened date or use by date. Daily temperature logs for recording refrigerator and freezer temperatures had missing entries, resulting in the potential for foodborne illness to spread. This had the potential to affect 31 out of 32 residents that eat orally.

Inspectors wroteBased on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 236 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 12 residents surveyed (R236).

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not consult with a physician for 1 of 3 residents (R) R26 who had experienced a significant weight gain. This is evidenced by: The facility policy entitled Change in Condition Policy: dated August 2024 states: The purpose of this policy is to ensure the facility promptly consults the physician when there is a change requiring notification. Procedure - .The physician will be notified when there has been a change that is marked a difference in usual sign/symptoms. Specific information that requires prompt notification include . significant weight change gain or loss of 5% or more in the past 30 days, 7.5% or more in past three months, or 10% or more in the past six months. R26 was admitted to facility on 11/15/23, and has diagnoses that include Alzheimer's disease, hypertension, and chronic pain. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for restraints (R3). R3 had a lap belt in his wheelchair without a physician order for use, the medical symptom the lap belt was being used to treat, or an assessment to determine appropriateness of its use. The device was not indicated in R3's care plan. This is evidenced by: The facility's policy titled Restraint Management, read in part .If indicated, the least restrictive restraint is used for the least amount of time. In cases where restraints are implemented based on the resident's assessment, the facility will make reasonable efforts to reduce their use systematically and gradually. [...]

Inspectors wroteBased on interview and record review, the facility did not report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 2 residents (R) reviewed for abuse (R187). This is evidenced by: The facility police entitled Abuse prevention Facility Procedures Training Program and Staff Materials defines Neglect: Means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect is the intentional carelessness, negligence, or disregard of policy or care plan which could cause or could be reasonably expected to cause pain injury or death. Section VII. External Reporting. 1. Initial Reporting of Allegations. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure 3 of 12 sampled residents (R11, R28, R20) reviewed for hospitalizations, received the proper notice of transfer, reason for transfer and location of transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 of 12 sampled residents (R28 and R20) reviewed for hospitalization, received notification of the facility's bed hold policy when they were transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility did not complete a Significant Change in Status Assessment (SCSA) for 1 resident (R11) of 12 sampled residents. R11 experienced a significant change in physical condition and cognition, identified on 09/12/24; the facility did not complete a SCSA for R11. This is evidenced by: According to the Resident Assessment Instrument (RAI) manual, a significant change is defined as: -A decline or improvement that will not resolve itself without staff intervention or standard clinical interventions. -A change that affects more than one area of the resident's health. -A change that requires a revision or interdisciplinary review of the care plan. Examples of a significant change in the resident's status include, in part: -A decline in two or more areas. -A decline in an Activities of Daily Living (ADLs) physical functioning. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R11). The facility did not follow hospital discharge orders to complete laboratory testing five days after R11 discharged from the hospital. The facility did not follow hospital discharge orders to complete a sleep medicine evaluation to determine possible interventions related to R11 refusing to wear continuous positive airway pressure (CPAP) device.

Inspectors wroteBased on record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by obtaining routine weights routinely for 1 resident (R26) who had a significant weight gain. This is evidenced by: The facility policy entitled Weight Management dated September 2024 states: Resident's nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight, unless the resident's clinical condition demonstrates that this is not possible. Accurate weights are obtained by having staff follow a consistent approach to weighing and by using an appropriately serviced and functional scale. Weight can be a useful indicator of nutritional status when in evaluated within the context of the individual's personal history and overall condition. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding. The facility did not follow current standards when checking feeding tube placement for 2 of 3 residents (R) investigated for feeding tube use (R24, R13). Findings Include: Example 1 The facility policy, entitled Care and Treatment of Feeding Tubes, dated April 2024, states: 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube): . a. Tube placement will be verified before beginning a feeding and before administering medications. Of note: [...]

Inspectors wroteExample 2 On 10/07/24 at 11:02 AM, Surveyor entered R29's room to check the labeling on the oxygen tubing that R29 used regularly. Upon entering, Surveyor encountered Assistant Director of Nursing (ADON) G with new oxygen tubing in hand and R29 still using the original tubing. Surveyor asked ADON G if the tubing that R29 was currently using was labeled to which ADON G stated no it was not, this is why I decided to change the tubing. Surveyor then asked if they would expect there to be a label on R29's oxygen tubing to which ADON G said yes, they would expect that to be completed every time there is an oxygen tubing change. Based on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R11 and R29) reviewed for respiratory care were provided care consistent with professional standards of practice. [...]

Inspectors wroteBased on interview and record review, the facility did not have a reliable system to account for the receipt, usage, disposition, and reconciliation of controlled medications for 4 out of 4 residents (R) reviewed and receiving controlled medications (R29, R1, R31, R286). Record review of the Controlled Substance Logs identified the logs were not accurate, as the quantity remaining of controlled medications was not accurately recorded. Sufficiently detailed records of receipt and disposition of controlled medications were not maintained to enable accurate reconciliation.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications and biologics were removed from stock supply in the medication storage room. This occurred for 1 of 3 medication carts/storage rooms observed. An opened multidose medication/solution in the medication storage room refrigerator was not labeled with an opened date and stocked biologics located in the medication storage room were expired.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not wear proper personal protective equipment for enhanced barrier precautions (EBP) when providing care. This had the potential to affect 2 of 12 residents (R) observed for infection control practices (R24, R27).

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R6) at high risk for pressure ulcer development, received the necessary treatment and services needed to prevent the development of a pressure injury. R1 was admitted to the facility with a brace and ace bandage on her leg. R1 was identified as being at risk for pressure injuries and a care plan was not developed. The facility did not assess the skin under the brace/ace bandage routinely, which lead to multiple pressure injuries. The pressure injuries became infected, which required R1 to be hospitalized and have a surgical procedure and antibiotics. Facility failure to assess R1's skin under her brace/ace bandage routinely led to the development of multiple pressure injuries which created a finding of immediate jeopardy that began on 05/15/24. [...]

Inspectors wroteBased on interview, facility procedure and documentation review, facility did not have the appropriate competencies and skill sets to provide care for 1 of 1 resident, out of a sample of 3, who had PI management (R2). Facility failed to have a qualified staff member trained in wound care management and wound vac experience onsite during R2's wound care.

Inspectors wroteBased on record review and interview, the facility did not consult with and notify the resident's (R) physician when the resident had a significant weight loss. This had the potential to affect 1 of 3 residents reviewed for weight loss (R4).

Inspectors wroteBased on observation, staff interview and record review, the facility did not follow proper food handling practice. This practice had the potential to affect all 35 of 39 residents residing in the facility. Staff are not documenting all temperatures on refrigerator/freezer temperature logs. Staff are not documenting all dishwasher temperatures on monthly temperature logs. Staff are not documenting all sanitization levels on the sanitization logs. Kitchen staff apply single use gloves without hand hygiene in the kitchen, touch ready to eat foods with bare hands and touch ready to eat foods with contaminated gloves

Inspectors wroteBased on interview and record review, the facility did not ensure that alleged violations involving abuse and misappropriation of property are reported immediately to the appropriate agencies for 1 of 2 residents reviewed (R14). An incident regarding R14 occurred on 10/01/23 and was reported to Social Worker (SW) O by R14 on 10/02/23. The incident of alleged abuse was not reported to State Agency (SA) within 2 hours. The abuse was not reported to the state agency until 10/05/23. This is evidenced by: The facility policy entitled, Abuse Prevention Program, states: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable. This occurred for 3 of 4 residents, Residents (R) R28, R1, and R29. R28, R1, and R29 have in-use insulin pens that were not dated at the time the insulin pen was first opened. This was evidenced by: On 10/17/23 at 9:00 AM, Surveyor observed medication pass with Licensed Practical Nurse (LPN) H and observed R28's Lantus insulin pen had a use by sticker on it, but it was not filled out. There was no date when the pen needed to be discarded. Surveyor asked LPN H if there were any other insulin vials or pens in the medication cart that could be checked for the date opened sticker. [...]

Inspectors wroteBased on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not sanitize shared equipment for 2 of 7 residents (R) R24, R13. Staff observed not sanitizing the mechanical lift between use for R24 and R13. This was evidenced by: The facility's policy, entitled Cleaning and Disinfection of Resident Care Equipment, dated March 2020, states: .Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident . On 10/17/23 at 3:05 PM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D move R24 from the Broda chair to bed using the Hoyer lift. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 39 residents at the facility during the onsite visit. Cardboard boxes on the ground outside of the kitchen door. A garbage bag was sitting on top of dumpster.