Meadowbrook at Oconto Falls

Inspectors wroteBased on interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 5 residents (R) (R1, R3, R4, R6, and R8) of 5 sampled residents in a total sample of 18 residents. R1 was admitted to the facility on [DATE]. Since admission, R1 expressed a desire to leave and attempted to leave on 7/6/26, 7/9/26, and 7/21/26. The facility did not evaluate R1 to ensure all possible safety measures were implemented to prevent harm. In addition, the facility had not begun discharge planning for R1 despite their continued desire to leave. R3, R4, R6, and R8 did not have current smoking assessments.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled residents or their legal representative was informed in advance of the risks and benefits of prescribed medication and provided consent to receive the medication. R1 was prescribed Sertraline (antidepressant medication). R1 was not informed of the risks and benefits and did not consent to receive the medication.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure allegations of misappropriation and neglect were reported to law enforcement and/or the State Agency (SA) for 2 residents (R) (R1 and R7) of 2 sampled residents. The facility was informed of suspected misappropriation involving R1. The allegation of misappropriation was not reported to local law enforcement or the SA. R7 required the assistance of two staff for mechanical lift transfers. R7 was transferred via sit-to-stand lift by 1 staff, fell to the floor, and sustained a head laceration. The SA wasn't notified of the allegation of neglect.

Inspectors wroteBased on interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R1) of 1 sampled resident. The facility was informed of suspected misappropriation involving R1. The facility did not thoroughly investigate the allegation and implement safety measures to prevent further misappropriation.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 resident (R) (R7) of 4 sampled residents received care and treatment based on their needs and medical orders. R7 had an order to wear Prevalon boots in bed to prevent skin breakdown. The order was not consistently followed. In addition R7's care plan did not contain an intervention for Prevalon boots.

Inspectors wroteBased on interview and record review, the facility did not ensure medically-related social services were provided to attain or maintain the highest practicable well-being for 1 resident (R) (R1) of 18 sampled residents. R1 was admitted to the facility on [DATE]. The facility did not ensure appropriate and safe discharge planning was implemented and R1's decision-making capacity was assessed.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R7 and R9) of 3 sampled residents. R7 was on enhanced barrier precautions (EBP) due to an indwelling catheter and had a diagnosis of urinary tract infection (UTI). R7's Foley catheter bag was observed on the floor without a barrier to prevent infection. R9 was on EBP due to a feeding tube and indwelling catheter and had diagnoses of sepsis and UTI. Staff did not wear a gown while changing R9's feeding tube dressing.

Inspectors wroteBased on observation and interview, the facility did not ensure the nurse staffing was posted daily. This practice had the potential to affect all of the 71 residents residing in the facility. The facility did not consistently post the required daily nurse staffing.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents with a non-pressure wound received treatment as ordered. R1 was admitted to the facility on [DATE] with a surgical wound on the lower spine. R1 did not have a treatment order for the wound until 5/22/26. R1's dressing was not changed while they resided at the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R1) of 6 sampled residents. R1 was not provided effective pain management from 5/19/26 through 5/22/26.

Inspectors wroteBased on interview and record review, the facility did not ensure they accurately acquired and administered medication for 1 resident (R) (R1) of 4 residents in a total sample of 6 residents. R1 was admitted to the facility with orders for Rexulti (an antipsychotic medication), Vyvanse (a central nervous system stimulant), Lyrica (used to treat nerve pain), fentanyl (an opioid medication) and biotin (a vitamin B supplement). The facility did not ensure the medications were acquired or administered as ordered.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R1 and R2) of 3 sampled residents. R1 was on a facility-provided list of resident who smoke, vape, or use nicotine. R1's safe smoking evaluation and care plan indicated vaping materials should be stored at the nurses' station. R1 kept vaping materials in R1's room and vaped inside the facility. R2 was on a facility-provided list of residents who smoke, vape, or use nicotine. R2's care plan indicated smoking materials should be stored at the nurses' station. R2's smoking materials were observed in R2's room.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. One of three medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the * residents residing in the facility. The 300 wing medication cart was unlocked and unattended during medication administration on 5/28/25.

Inspectors wroteBased on observation, staff 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 disease and infection for 4 residents (R) (R1, R35, R30, and R15) of 6 residents observed during medication administration and the provision of cares. R1 was on enhanced barrier precautions (EBP). Staff did not wear a gown and gloves at all times during a pressure wound dressing change or urostomy and colostomy care. Staff did not complete proper hand hygiene before or after preparing medication and prior to administering medication to R35, R30, and R15.

Inspectors wroteBased on staff interview, and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R24) of 3 sampled residents. R24's wound care order was changed following a wound clinic appointment on 5/19/25. The facility did not implement the new order or order the needed supplies in a timely manner. In addition, the facility did not notify R24's physician or obtain an alternate order until the supplies could be obtained.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate assistance to prevent accidents was provided for 1 resident (R) (R43) of 3 sampled residents. R43 was observed without care planned fall prevention interventions on multiple occasions from 5/27/25 to 5/29/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the necessary care and treatment to prevent weight loss and dehydration was provided for 2 residents (R) (R40 and R51) of 5 sampled residents. R40 had significant weight loss. Weekly weights were not implemented per Registered Dietician (RD)-G's recommendation and a nutrition care plan was not implemented timely. R40's quarterly evaluation for nutrition, dated 4/2/25, contained a weight from 1/6/25 and did not indicate a current weight was requested at the quarterly review. In addition, R40's family's request to evaluate R40's stomach issues was not completed timely. R51 had severe weight loss without appropriate follow-up. In addition, R51 had an order for weekly weights which was not implemented or completed.

Inspectors wroteBased on staff interview and record review, the facility did not develop a culturally competent, trauma-informed care plan for 1 resident (R) (R33) of 2 sampled residents with an identified trauma history and intermittent issues with coping and functioning related to surviving trauma. R33 was a trauma survivor. The facility did not develop a trauma-informed plan of care to address R33's firework-related trauma. On 5/24/25, there was a fireworks show near the facility.

Inspectors wroteBased on observation, staff, resident, resident representative interview, and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R2) of 10 sampled residents. R9 had a history of sexually inappropriate behavior toward residents and staff. R2 had a history of wandering in and out of residents' rooms unsupervised. On 10/23/24, R10 reported to R2's Guardian (GDN-O) that R9 had groped R2's breast in the dining room. GDN-O reported the allegation to Nursing Home Administrator (NHA)-A. R2 was not assessed for injury and there were no interventions put in place to supervise R9 and R2. The facility's failure to supervise a resident with a history of sexually inappropriate behavior and a vulnerable resident who wandered in the facility unsupervised created a finding of immediate jeopardy that began on 10/23/24. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not acknowledge nor make a prompt effort to resolve grievances for 5 residents (R) (R3, R4, R6, R7, and R8) of 10 sampled residents. R3 filed a grievance regarding R2 wandering into R3's room unsupervised. The facility did not implement interventions to prevent R2 from wandering into R3's room. R3 indicated R2 continued to wander into R3's room and the grievance was not resolved. R4, R6, R7, and R8 verbally notified staff that R2 repeatedly wandered into their rooms and was not welcome in their rooms. The facility did not document R4, R6, R7, and R8's concerns as grievances and did not implement interventions to prevent R2 from wandering into their rooms.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R2) of 10 sampled residents. R10 and R2's Guardian (GDN-O) reported an allegation of sexual abuse that occurred on 10/23/24. The facility did not report the allegation to the SA.

Inspectors wroteBased on staff, resident, resident representative interview and record review, the facility did not report an allegation of sexual abuse to the State Agency (SA) for 1 resident (R) (R2) of 10 sampled residents. R10 and R2's Guardian (GDN-O) reported an allegation of sexual abuse that occurred on 10/23/24. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure appropriate supervision was in place for 1 resident (R) (R2) of 3 residents who wandered and was physically and verbally aggressive. R2 wandered throughout the facility and was physically and verbally aggressive. The facility did not appropriately supervise R2 to protect R2 and other residents. In addition, the facility did not revise R2's plan of care to include behavioral and monitoring interventions.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure care plans were updated for 4 residents (R) (R3, R4, R5, and R2) of 7 sampled residents. R3's care plan was not updated to indicate R3 frequently called out and did not include interventions to offer R3 when R3 called out. R4's care plan was not updated with interventions to offer R4 when R4 expressed concern about another resident frequently calling out. R5's care plan was not updated with interventions to offer R5 when R5 expressed concern about another resident frequently calling out. R2's care plan was not updated to indicate R2 no longer required 1:1 supervision.

Inspectors wroteBased on staff and resident interview and record review, the facility did not thoroughly investigate and resolve grievances for 2 residents (R) (R4 and R5) of 7 sampled residents. R4 and R5 expressed concerns to staff that R3 frequently called out. Grievance forms were not completed and the grievances were not thoroughly investigated or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the provision of a safe environment that was free of accident hazards for 1 resident (R) (R1) of 5 sampled residents. On 5/17/24, R1 reported to staff that R1 fell out of a Hoyer lift when Certified Nursing Assistant (CNA)-C transferred R1 alone. On 5/18/24, R1 went to the hospital and was diagnosed with a left hip fracture. In addition, staff did not adequately assess R1 following R1's reported fall and had increased pain which delayed R1's diagnosis.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 51 residents residing in the facility. The facility did not have an RN on duty from 5/17/24 at 6:05 PM until 5/19/24 at 12:00 PM.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. The facility did not maintain an infection tracking and surveillance log which had the potential to affect all 50 residents residing in the facility. In addition, staff did not perform appropriate hand hygiene or sanitize equipment during the provision of cares for 2 residents (R) (R30 and R4) of 2 residents and did not don appropriate personal protective equipment (PPE) for 1 (R2) of 2 residents on transmission-based precautions. The facility did not consistently maintain infection surveillance logs designed to assist with the detection of disease transmission patterns. [...]

Inspectors wrote4. R1 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, anxiety, depression, and insomnia. R1's MDS assessment, dated 4/3/24, stated R1 had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. Between 4/28/24 and 4/30/24, Surveyor reviewed R1's medical record and noted R1 was prescribed the following medications with a black box warning: lorazepam 1 milligram (mg) every 12 hours for anxiety; escitalopram 5 mg for depression; duloxetine 90 mg for depression; Ambien 10 mg for insomnia; and Benadryl for anxiety. Surveyor reviewed R1's Informed Consent for Mediation documents for the above medications. Surveyor noted the consents for the medication were signed by R1 on 4/24/24, but pages one, two, and three were not initialed and dated by R1. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 4 residents (R) (R17, R18, R20, and R23) of 5 residents reviewed for vaccines. The facility did not review R17's vaccination history or offer R17 the PCV20 (Prevnar 20®) vaccine. The facility did not review R18's vaccination history or offer R18 the Prevnar 20® vaccine. The facility did not review R20's vaccination history or offer R20 the Prevnar 20® vaccine. The facility did not review R23's vaccination history or offer R23 the Prevnar 20® vaccine.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure mechanical lift equipment used to transfer residents was maintained in a safe operating condition. This had the potential to affect 17 residents who were transferred via lift. The facility's mechanical lift equipment showed signs of wear and tear. Residents and staff expressed concerns with the condition of the equipment and the length of time it took to transfer residents. In addition, the emergency pull was broken on one of the lifts.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent the development of or promote healing for 1 resident (R) (R4) of 3 residents reviewed for pressure injuries. R4 had a pressure injury on the left heel. During observations on 4/28/24 and 4/29/24, R4 was not wearing a left heel boot as ordered. Certified Nursing Assistant (CNA) staff was not aware R4 should wear a heel boot when out of bed and R4's care plan was not updated to reflect the intervention.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R20 and R18) of 2 residents with indwelling catheters. R20 and R18's uncovered catheter drainage bags were observed in contact with the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12 and R2) of 3 residents with respiratory needs were provided with the necessary care and treatment. R7 used oxygen therapy. R7 did not have a physician's order for oxygen therapy. In addition, R7's plan of care did not address the use oxygen therapy. R12 and R2 were on droplet and contact precautions. R12 and R2's medical records did not contain consistent monitoring or assessments.

Inspectors wroteBased on staff interview and record review, the facility did not ensure they had a signed and dated contract that contained the correct name of the dialysis center for 1 resident (R) (R46) of 1 resident who received dialysis services. R46 received treatment at a dialysis center three times weekly. The facility did not have an accurate signed and dated contract with the dialysis center to ensure agreed upon communication and services were in place to provide the necessary care and treatment.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely administration of all drugs and biologicals for 1 resident (R) (R30) of 23 sampled residents. R30 was prescribed Fiasp (a short-acting insulin used to treat high blood sugar) with dosing based on blood sugar levels. On 4/29/24, R30 did not receive R30's morning dose of Fiasp timely following a blood sugar check.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse reactions or the effectiveness of psychotropic medication was initiated for 1 resident (R) (R48) of 5 residents reviewed for unnecessary medications. R48 was prescribed mirtazapine (an antidepressant medication). R48's plan of care did not contain interventions for staff to monitor R48 for adverse reactions or the effectiveness of mirtazapine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 5 errors occurred during 25 opportunities which resulted in a 20% medication error rate that affected 3 residents (R) (R2, R23, and R30) of 3 residents observed during medication pass. On 4/29/24, R2 was administered an incorrect dose of Miralax (used to treat/prevent constipation). On 4/29/24, R23 was administered the wrong medication for vitamin B-complex with folic acid (used as a supplement), was administered the wrong dose of vitamin B-12 (used as a supplement), and was administered the wrong medication for a multivitamin (used as a supplement). On 4/29/24, Surveyor intervened before staff administered an incorrect dose of Fiasp (a fast-acting insulin used to treat high blood sugar).

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy and complete timely background checks for 5 of 8 staff reviewed. Maintenance Staff (MS)-C had a conviction that required the facility to obtain further information prior to employment. The facility did not obtain further information regarding the conviction. Activity Aid (AA)-F, Social Worker (SW)-G, and Certified Nursing Assistant (CNA)-H did not have a background check completed within the past 4 years. CNA-E did not have a new background check completed after a more than 30 day lapse in employment with the facility.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not meet state minimum staffing requirements, did not address resident council complaints and resident grievances regarding insufficient staffing, and did not ensure sufficient nursing staff to answer residents' call lights and provide care in a timely manner. This had the potential to affect all residents residing in the facility. Staffing levels were below the state minimum staffing requirement of 2.5 skilled nursing staff hours per Resident (R) per day on three (2/23/23, 2/25/23, and 3/4/23) of fourteen days reviewed. Staff did not answer call lights and meet needs for residents R27, R30, R20, R56, R51, and R54 in a timely manner. R20 had 3 documented showers between 1/11/23 and 3/15/23. R50 was not checked and changed and remained in a soiled brief from approximately 5:00 PM until 10:06 PM. [...]

Inspectors wrote2. During record review on resident council meeting notes, Surveyor noted insufficient staffing documented as a concern on monthly meeting minutes for November 2022, December 2022, and January 2023. On 3/14/23 at 2:01 PM, R15, R17, R22, R29, R30, R43 and R44 participated in a group interview with Surveyors and all expressed concerns with staffing levels. R22, who was the resident council president, and R44, who attended resident council meetings regularly, stated staffing concerns were repeatedly brought up at resident council meetings, but were not addressed by the facility. In addition, most residents denied knowledge of the facility's grievance officer. When Surveyor inquired about communication with staff following concerns, R30 stated, We tell the aides and that's as far as it goes. R30 stated there is no follow-up by the facility after concerns are communicated to staff. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure staff performed proper hand hygiene for 4 Residents (R) (R48, R19, R268 and R51) of 8 residents observed during medication administration. On 3/15/23, Licensed Practical Nurse (LPN)-M did not consistently perform appropriate hand hygiene when obtaining R48's blood sugar level. On 3/15/23, LPN-M did not consistently perform appropriate hand hygiene when obtaining R19's blood sugar level and administering R19's insulin injection. On 3/16/23, LPN-S did not consistently perform appropriate hand hygiene following administration of R268's insulin injection. On 3/16/23, LPN-S did not consistently perform appropriate hand hygiene prior to, during and after preparation of R51's oral medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R19) of 1 sampled resident with a guardian was provided services following State Statute Chapter 55.03(4) which requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be least restrictive and in the best interest of the resident. R19 was admitted to the facility on [DATE] and had a legal guardian. The most current protective placement (temporary or permanent) court documentation contained in R19's medical record was dated 6/9/21. The facility did not ensure R19's protective placement was reviewed annually.

Inspectors wroteBased on staff interview and record review, the facility did not ensure PASRR (Pre-admission Screen and Resident Review) requirements were met for 3 Residents (R) (R58, R167 and R3) of 16 sampled residents. R58 did not have a PASRR Level 2 Screen completed after R58's 30 day exemption expired. R167's Level 1 PASRR Screen was completed late. R3's Level 1 PASRR Screen was completed late.

Inspectors wrote2. R56 was admitted to the facility on [DATE] with diagnoses to include dependence on supplemental oxygen, chronic obstructive pulmonary disease (COPD), shortness of breath, major depressive disorder and had a recent bout of influenza A and pneumonia. R56's MDS assessment, dated 1/8/23, contained a BIMS score of 15 out of 15 which indicated R56 had intact cognition. On 3/13/23 at 6:32 PM, Surveyor interviewed R56 and noted R56 had difficulty speaking. Surveyor noted R56 became tired easily, was breathy and used partial words. Surveyor then asked R56 yes or no questions and R56 shook a fisted hand yes or no to answer the questions. R56 shook yes when asked if R56 could hear and understand the questions. R56 shook yes when asked if R56 had a difficult time getting words out. R56 did not indicate any distress at the time. [...]

Inspectors wroteBased on resident and staff interview and record review, the facility did not ensure 1 Resident (R) (R20) of 16 residents received weekly showers as scheduled. R20 did not receive weekly showers as scheduled. In addition, R20s bed linens were not changed regularly.

Inspectors wroteBased on observation, resident and staff interview and record review, the facility did not ensure treatment and care in accordance with professional standards of practice for 2 Residents (R) (R19 and R48) of 3 residents reviewed for insulin administration. On 3/15/23, R19 was administered a short-acting insulin dose based on a blood sugar level taken over an hour prior to the administration. In addition, on 3/16/23, the facility did not follow their policy in response to R19's hypoglycemia (low blood sugar) incident. From 3/1/23 through the breakfast dose on 3/16/23, ten of forty six insulin doses administered to R48 were incorrect based on R48's physician order.

Inspectors wroteBased on observation, staff interview and record review, the facility did not provide proper assistance in maintaining hearing ability for 1 Resident (R) (R55) of 16 residents reviewed. R55 had hearing aids that R55 did not wear. Staff documented R55's hearing aids were put in and taken out daily. In addition, R55's communication care plan was not updated and did not include approaches for successful communication with R55 when R55 did not wear hearing aids.

Inspectors wroteBased on staff interview and record review, the facility did not ensure accurate and safe administration of medication for 1 Resident (R) (R68) of 17 sampled and supplemental sampled residents. On or about 11/29/22, R68 reportedly self-administered a dose of ondansetron (an antiemetic medication used to prevent nausea and vomiting) which was left at R68's bedside. R68 was assessed as not safe to self-administer medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 38 opportunities which resulted in a 5.26% medication error rate affecting 2 Residents (R) (R19 and R48) of 8 residents observed during medication pass. On 3/15/23, R19 was given a short-acting insulin dose based on a blood sugar taken over an hour prior which was not in accordance with acceptable standards of practice. On 3/15/23, R48 was given an insulin dose not in accordance with the math requirements of R48's physician order.