Meadowbrook at Chetek

Inspectors wroteBased on interview and record review, the facility did not ensure a safe discharge for 1 of 3 residents (R1) reviewed of a sample of 4 residents. R1 was not allowed to return to the facility after R1 left the building and did not return prior to 11:59 PM. R1 was located by facility staff the next day and given paperwork for discharge against medical advice. R1 was discharged without a safe discharge plan, without R1's belongings or medications. This is evidenced by: Facility policy titled, Administrative Transfer/Discharge Notice, with a revised date of 12/2025, states: Purpose: It is the policy of the facility to provide each operating facility with a process for resident discharges that are initiated by the facility. Of note: policy does not include guidelines of a resident not returning by 11:59 PM being discharged AMA (against medical advice). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive infection prevention and control program was established and maintained. Specifically, the facility failed to ensure staff used Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP), sanitize mechanical lifts between resident use, complete proper hand hygiene, or provide residents with hand-hygiene before meals.-Registered Nurse (RN) C and Licensed Practical Nurse (LPN) D entered R23's room and conducted wound care on R23's open leg wounds without donning PPE prior to and during wound care treatment, having the ability to potentially spread infection to all 75 residents in the facility.-Certified Nursing Assistant (CNA) R and LPN D did not wear PPE while transferring R4 with the Hoyer mechanical lift.-CNA J and CNA G did not clean/sanitize the Hoyer lift after use on R3 [...]

Inspectors wroteBased on record review and interview, the facility did not ensure each resident is free from unnecessary drugs as evidenced by facility not providing adeuate drug monitoring for 5 of 5 residents (R) (R2, R5, R9, R11 and R45) reviewed for unnecessary medication reviews. R2 received Hydroxyzine HCl 25 mg by mouth one time a day related to anxiety disorder, unspecified. Physician orders stated for facility to document number of times the resident [R2] exhibits the following behaviors, Nervousness, Restlessness, sweating, increased heart rate, difficulty sleeping or trouble concentrating.)R2 received Trazodone HCL 50mg one time a day for insomnia. Physician orders stated for facility to document number of times the resident exhibits the following behaviors: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 resident (R) of 18 residents reviewed for residents' rights can exercise their rights without interference, coercion, discrimination, or reprisal from the facility in a sample of 18 residents (R10). The facility did not allow R10 an advanced diet unless R10 ate meals in a common dining area instead of in R10's room per R10's preference resulting in R10 refusing puree consistency meals, which in turn contributed to weight loss. The facility did not provide R10 and R10's family education on risks and benefits of R10 consuming regular texture meals brought in by R10's family which could result in R10 suffering physical harm due to R10 having dysphagia (difficulty swallowing).

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident, including services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (R) reviewed for care planning (R15).-R15 has an open surgical wound with a wound vac present, and a laceration to 5th left toe with no care plan related to Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the comprehensive care plan was reviewed and revised for one resident (R) of 18 residents reviewed for care plan timing and revisions in a sample of 18 residents (R10). R10's comprehensive care plan did not:- Include interventions for R10's refusal to wear dentures and how that affects R10's nutritional status which could contribute to R10's weight loss.- Include interventions for R10 refusing to eat meals and alternative meal options provided to R10 which could contribute to R10's weight loss. - Include interventions for R10 refusing tube feedings which could be contributing to R10's weight loss.

Inspectors wroteBased on observation, interview, and record reviews, the facility did not ensure services provided met professional standards for 2 of 4 residents (R) reviewed for medication pass. (R72 and R10).- Registered Nurse (RN) Q did not cue or assist R72 to blow nose prior to administration of nasal inhalant medication.- Licensed Practical Nurse (LPN) M did not properly check for gastrostomy tube placement prior to administering medications to R10. Example 1 Cleveland Clinic article dated February 18, 2026, under the heading, How To Correctly Use Nasal Spray, indicates, . Shake the nasal spray well. Wash your hands. Scrub your hands thoroughly with soap and water. Before applying, gently blow your nose. This will empty your nasal passages and clear the way for the medicine. R72 was admitted on [DATE] with diagnoses of congestion, nasal crusting, and rhinorrhea. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 18 residents (R) (R9, R10, and R15) reviewed for following physician orders. -Facility failed to notify physician on four occasions when R9's fluid restrictions exceeded 2500 cc in 24 hours as per physician ordered parameters. -Facility failed to provide thorough speech therapy services for R10 which contributed to R10's weight loss as R10 did not wear dentures. -R15's hospital discharge orders were omitted when readmitted , following surgical procedure on R15's left thigh requiring a wound vac. Example 1 R9 was admitted to facility on 06/19/2024 with diagnosis of Cor pulmonale, chronic respiratory failure, and chronic kidney disease. R9's care plan initiated on 06/28/2024, states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 3 residents (R) reviewed for foot care (R15).-R15's physician discharge orders from hospital were omitted for treatment to the left foot/toes and a follow-up appointment with podiatry was not made for R15.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with an indwelling catheter receive the appropriate care and services to prevent urinary tract infections to the extent possible for 3 of 7 residents reviewed for indwelling catheters (R1, R6, R80).-R1 was observed with R1's catheter drainage bag in the wheelchair seat beside R1.-R6 was observed with R6's catheter drainage bag in the wheelchair seat beside R6 with staff present and no intervention.-R80 was observed with R80's catheter drainage bag and privacy bag wrapped around front wheelchair wheel for 24 minutes without intervention by 4 staff, who were present.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice for 1 of 2 residents (R) reviewed for nephrostomies (R6).-R6's nephrostomy tubes were placed up and over the back of the wheelchair and placed in a pouch above the kidneys.

Inspectors wroteBased on interview and record review the facility did not ensure that a system is in place to ensure that residents are free of any significant medication error for 6 of 9 residents (R) (R1, R3, R5, R7, R8, and R9) reviewed for medication errors. R1 is cited at a scope and severity level of G (actual harm that is not immediate jeopardy/isolated). R1 was administered R2's medications, which required R1 to receive Narcan and hospitalization. R3 was administered incorrect pain medication. R5 was administered medication that was discontinued and wrong dosage form. Pharmacy found that R7 had the wrong dose in the medical record for R7's Tacrolimus. R8 received a different resident's 40 mg tab of Atorvastatin. [...]

Inspectors wroteBased on interview and record review, the facility did not report an incident of potential neglect to the state agency immediately upon learning of an incident wherein resident (R) received the wrong medication which required administration of Narcan and hospitalization, nor did the facility submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 8 residents (R1). The facility policy titled Abuse prevention program facility procedures training program and staff materials undated, states under Option 5: Possible Neglect: [...]

Inspectors wroteBased on record review and interviews, the facility failed to conduct a thorough investigation and implement corrective action in a timely manner for 1 of 8 residents (R) R3, resulting in 2 additional significant errors to occur for R1 and R5. R3 was administered incorrect opioid pain medication on 07/02/25. R1 was administered medications for R2, which required receiving Narcan and hospitalization on 07/04/25. R5 was administered medication that was discontinued and wrong dosage form on 07/06/25. The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner. Under section labeled Procedure states in part the following: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a system was in place to establish disposition of destroying controlled drugs for 2 of 6 residents (R) (R2 and R5) reviewed for medication errors. R2's Lyrica was not destroyed in a timely fashion and by 2 licensed nurses. R5's Lorazepam medication was discontinued and not removed from circulation. The facility policy titled, Destruction of Unused Drugs, revised [DATE], states: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. This includes having a witness to medications being destroyed. Example 1On [DATE] at 1:25 PM, Surveyor reviewed R2's Narcotic sheet that states, .[R2] is to be given Pregabalin (Lyrica) 50 mg capsule by mouth two times a day ordered on [DATE]. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that a system was in place to ensure residents receive medications that are properly labeled and administered accordingly for 2 of 8 residents (R5, R6) reviewed for medication errors. R5 was administered medication that was discontinued and incorrect dosage form. R6 was administered medication without proper labeling. The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner. Under section labeled Procedure states in part the following: If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Never administer medications from an unmarked container. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 71 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors, no gradual dose reductions (GDR) for the first year were completed, and non-pharmacological interventions were implemented, for use of the medications for 5 of 7 residents (R6, R21, R32, R53 and R261) reviewed. R6 receives psychotropic medications. R6 does not have a care plan identifying individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic and anti-anxiety medications use. R21 receives psychotropic medications. R21 does not have a care plan for individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic medication use. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 18 residents (R) (R34) reviewed. R34's call light was observed to be out of reach. This is evidenced by: Facility policy titled, Fall Management, with a revised date of October 2024, states in part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive device, and/or functional programs, as appropriate, to minimize the risk for falls. R34 was admitted to the facility on [DATE] with pertinent diagnoses of monoplegia of upper limb affecting left non-dominant side (paralysis/weakness of one limb) and chronic obstructive pulmonary disorder (COPD). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing infection and promote healing for 1 of 1 resident (R) R20, reviewed for PIs. R20 was not provided PI treatment as ordered, and staff did not perform hand hygiene during PI treatment to prevent infection. This is evidenced by: R20 was admitted to the facility on [DATE]. R20's current diagnoses include in part, sepsis, surgical aftercare, muscle weakness, end stage renal disease, dependence on renal dialysis, diabetic mellitus type 2, peripheral vascular, infection of skin and subcutaneous tissue, acquired absence of right leg below knee, and venous insufficiency chronic peripheral. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 2 of 4 residents (R) R23, R20, reviewed for accidents/falls. R23 had a fall in the bathroom after being left unsupervised for an extended period of time. R20 vapes and was not assessed to vape/smoke independently and a smoking care plan was not developed. This is evidenced by: Example 1 Facility policy titled, Fall Management, with a revised date of October 2024, states in part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive device, and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 sampled resident (R20) reviewed for dialysis. The facility failed to provide ongoing assessment of R20's condition and monitoring for complications before and after dialysis treatments. This is evidenced by: Facility's policy titled Hemodialysis with the revision date of March 2023, read in part, The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 8. [...]

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 for 3 of 18 residents (R) (R20, R6, and R26) observed. Facility staff did not conduct appropriate hand hygiene when providing wound care for R20 and personal cares for R6. R20 has open wounds, and the facility did not implement enhanced barrier precautions (EBP), and staff did not wear personal protective equipment (PPE) when providing wound care. R26's urinary bag was observed on the floor. This is evidenced by: Facility policy titled: Hand hygiene last revised on 09/22 states: Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness for 57 of 59 residents reviewed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R), R1, of 3 sampled residents reviewed for conveyance of resident funds, had funds returned to the Power of Attorney (POA), family, or estate within 30 days of resident death. The facility did not refund R1's trust funds to POA within 30 days of death.

Inspectors wroteBased on interview and record review, the facility did not immediately report to the physician on call post falls for 2 of 3 residents (R) reviewed for falls (R1 and R2).

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 2 of 3 residents (R) reviewed. (R1 and R2) R1 and R2 did not receive accurate assessments and treatment following falls.

Inspectors wroteBased on interview and record review, the facility did not ensure new care planned fall interventions were put into place post falls to prevent further incidents from occurring for 3 of 3 residents (R) R1, R2, and R3 reviewed for falls. R1 was at risk for falls and had a fall on 09/09/24. Facility did not implement new interventions post fall. R2 was at risk for falls, and had two falls, one on 10/09/24 and one on 10/24/24. Facility did not implement new interventions post fall. R3 was at risk for falls and had a fall on 10/21/24. Facility did not implement new interventions post fall.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper hand hygiene with food handling in accordance with professional standards for food service safety. Dietary staff did not use hand hygiene after touching dirty surfaces and continued to serve food; also hair nets were not used in areas that require hair nets. This has the potential to affect one resident who would receive the coffee, and 4 plates prepared in an unsanitary manner.

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 16 sampled residents (R161). The facility did not follow physician orders for R161, to obtain a follow up oncology appointment after a newly diagnosed condition requiring further evaluation, within 2-4 days after admission.

Inspectors wroteBased on observation, interview and record review, the facility did not evaluate for hazards or risks related to oscillating percussion vest for a resident with a diagnosis of quadriplegia and assessed as high risk for aspiration. Deficiency identified for 1 of 6 residents (R26) reviewed for accidents.

Inspectors wroteBased on observations, record review and interview, the facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with 1 of 1 resident (R38) observed for medication administration through a G-tube. R38 received medication without ensuring the G-tube was appropriately placed prior to medication administration.

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. Staff did not perform proper hand hygiene during medication administration with Resident (R) 32 and the facility removed droplet precautions on R10 before the required isolation period was complete. This has the potential to affect 2 of 9 residents (R32, R10) observed for medication administration and contact precautions. Staff did not perform proper hand hygiene during medication administration with R32. Facility removed droplet precautions on R10 before the required isolation period was complete.

Inspectors wroteBased on record review and interview, the facility did not provide necessary respiratory care and services related to Trilogy, (an all-in-one device, capable of delivering both invasive and non-invasive ventilation) consistent with professional standards of practice for 1 of 1 resident (R1). *R1's hospital referral received on [DATE] stated R1 used a BiPAP while in the hospital. Facility did not question hospital if BiPAP was to be continued once discharged to the skilled nursing facility. *R1's discharge orders on [DATE] stated BiPAP at night for OSA (Obstructive Sleep Apnea), which was transcribed under laboratory orders by the facility upon admission. *R1 did not receive BiPAP until family brought machine in on [DATE]. R1 went 3 days without BiPAP machine. This is evidenced by: [...]