Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook At Black River Falls during CMS and state inspections, most recent first.
Unsanitary food handling and improper dry food storage were observed when a Dietary Aide brought a dirty plate from the dining room back to the hot food service area and staff placed more food on it before returning it to a resident. Surveyors also found multiple dry food items stored only 2 to 4 inches off the floor, below the facility’s 6-inch storage requirement.
Staff failed to follow infection control practices during laundry handling, tube feeding care, and medication administration. Clean laundry was transported uncovered through the facility, an LPN provided PEG tube care without the required gown and moved between rooms in the same scrubs, and nurses entered contact precaution rooms without PPE. Hand hygiene was also missed before glove use and between dirty and clean tasks during eye drop administration, wound care, and tube feeding care.
Unnecessary Psychotropic Medication Use: Multiple residents were given psychotropic medications without adequate documented indication or supporting assessment. One resident with dementia received quetiapine with no documented behaviors, another resident received scheduled diphenhydramine-APAP for sleep and lorazepam without documented behaviors, a resident with schizophrenia had risperidone and sertraline without psychiatric follow-up or behavior documentation, and another resident received duloxetine for depression without supporting documentation in the record.
Missing transfer, bed-hold, and Ombudsman notifications: The facility did not consistently provide written transfer notices with required details, bed-hold information, or evidence of Ombudsman notification for multiple residents sent to the hospital or discharged. Residents with complex medical conditions, including altered mental status, weakness, NSTEMI, urinary issues, and hearing/speech impairment, were transferred or discharged without the required documentation being maintained.
Failure to acknowledge pharmacy medication review recommendations. A resident with anxiety, depression, insomnia, and repeated unwitnessed falls had a pharmacist note that several meds may have contributed to falls, but no provider response was documented. Another resident with schizophrenia had repeated pharmacist recommendations for GDR of psychotropic meds with no timely provider response, and a third resident with depression had repeated recommendations for GDR of duloxetine that were left blank, unsigned, or otherwise not addressed.
A resident admitted with paranoid schizophrenia and receiving psychotropic medications had a Level I PASRR that identified serious mental illness and a hospital discharge exemption with a 30-day maximum stay. The resident remained beyond the exemption period, but no additional PASRR screening was completed, and SS staff later stated the follow-up screen should have been done.
A resident with dementia and mobility limitations was left in bed for an extended period because all mechanical lift slings were being washed and unavailable. Staff confirmed the resident could not be transferred out of bed as required by their care plan, and this was communicated to the responsible party. Facility leadership acknowledged that slings should not have been washed simultaneously, resulting in the resident's ADL needs not being met.
A resident with a history of methamphetamine and alcohol use disorder did not have care plans or physician orders addressing substance use monitoring, despite facility policy. After the resident used methamphetamine during their stay, staff education lacked specific guidance on identifying or monitoring substance use, and staff interviews revealed insufficient knowledge and documentation regarding SUD assessment and monitoring.
The facility failed to administer correct anticoagulation therapy for two residents, resulting in significant medication errors. One resident did not receive the correct Warfarin dose due to a failure to verify and transcribe new physician orders, leading to an emergency department visit and additional treatment. Another resident's Warfarin orders were not properly documented or verified, indicating a systemic issue in managing anticoagulation therapy.
A resident with a history of mental health and chronic conditions self-administered medications left unattended by the DON, despite being assessed as incapable of self-administration. The facility's policy requires medications to be under direct observation or locked away, which was not followed in this instance.
A medication cart was left unlocked and unattended outside a resident's room, contrary to the facility's policy requiring all medication carts to be locked when not attended. An LPN admitted to not locking the cart, and the DON confirmed that the expectation is for all carts to be locked when unattended.
The facility did not have a qualified director of food and nutrition services, as the Dietary Manager had not started certification classes and lacked necessary qualifications. The Registered Dietician was only present one day a week, with additional support from a Certified Dietary Manager from a sister facility. This deficiency could potentially affect all 31 residents.
The facility failed to maintain a clean and sanitary environment for food preparation, affecting all 31 residents. Staff did not consistently label food items, test sanitizing solutions, or document refrigerator, freezer, and dish machine temperatures. Observations included staff touching ready-to-eat food with contaminated gloves and delivering uncovered food items to resident rooms, violating facility policies.
A facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions. An RN did not sanitize bandage scissors and a marker before and after use, and reached into their uniform pocket with contaminated gloves. The DON confirmed these actions did not follow correct procedures.
The facility did not post daily nurse staffing information at the beginning of each shift, as required by federal regulations. This issue was identified when a surveyor could not find the postings on two consecutive days. The new NHA was unaware of the posting location, and the ADON later revealed that the previous NHA had not communicated the responsibility for posting the staffing data, resulting in a lapse since October, affecting all 31 residents.
A resident with a history of elopement was admitted to a facility and managed to elope three times due to inadequate supervision. Despite being identified as an elopement risk, the facility delayed implementing interventions like a wanderguard and failed to document or increase supervision after the first two elopements. The third elopement involved the resident running through traffic and attempting to jump off a bridge, highlighting the facility's failure to provide adequate supervision and staff training.
The facility failed to adhere to professional standards for food service safety by not labeling opened milk and juice containers with use-by dates and not maintaining complete daily temperature logs for refrigerators and freezers. This deficiency had the potential to affect 31 out of 32 residents who eat orally.
A resident with a complex medical history eloped from the facility three times in one day, with the second and third incidents involving law enforcement and emergency medical intervention. Despite the seriousness of these events, the facility failed to report them to the state agency as required, and the Chief Nursing Officer and Nursing Home Administrator were unaware of the reason for the lack of reporting.
A resident with a history of heart attack, COPD, and other conditions experienced a significant decline in cognition and physical health, including hallucinations and pressure ulcers. Despite these changes, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. The deficiency was identified during a surveyor's observation and interviews with staff, who confirmed the resident's refusal to reposition in bed and complete treatments.
A facility failed to follow hospital discharge orders for a resident with respiratory issues, including obstructive sleep apnea. The resident's post-discharge care instructions, which included laboratory testing and a sleep medicine evaluation, were not completed in a timely manner. Additionally, the facility did not conduct a comprehensive assessment of the resident's change in condition, which included hallucinations and physical decline.
A resident's advance directive documentation was not maintained in the facility's records. Despite being capable of understanding and communicating their wishes, the resident's CPR or DNR status was not documented in their hard charts or electronic records. Interviews with staff, including an LPN and the CNO, confirmed the absence of necessary documentation in both the electronic record and the Post Book.
A resident with Alzheimer's disease experienced a significant weight gain of 7.2% over one month, but the facility failed to notify the physician as required by their policy. Despite being aware of the weight change, the facility did not update the PCP after a five-day weight monitoring period, only doing so after a surveyor's review.
A resident with paralysis and severe cognitive impairment was found with a lap belt in their wheelchair without a physician order or documented assessment. The facility's policy on restraint management was not followed, as the restraint was used out of habit rather than medical necessity. Interviews revealed the resident could not remove the belt independently, and the ADON confirmed the lack of documentation and removed the restraint.
The facility did not provide written notices of transfer for three residents who were hospitalized. One resident was admitted to the hospital with a complicated UTI and a chronic Foley catheter, but neither they nor their representative received a notice. Medical Records C confirmed the absence of a process for issuing such notices.
The facility failed to notify two residents of its bed hold policy during hospital transfers, as required by its policy. One resident, who was his own decision maker, was hospitalized twice without receiving notification. Another resident was transferred to the hospital with a complicated UTI, and their representative was not informed of the bed hold policy. The Social Services Director could not locate the required notifications, highlighting a lapse in policy adherence.
A resident with Alzheimer's disease experienced a significant weight gain, which was not on a physician-prescribed regimen. The facility's policy requires regular weight monitoring and communication of significant changes to the attending physician. However, despite awareness of the weight changes, the Medical Doctor was not updated after a five-day monitoring period, contributing to a deficiency in maintaining the resident's nutritional status.
The facility failed to ensure proper feeding tube management for two residents, as staff used outdated auscultation methods to check tube placement, contrary to current standards. One resident with cognitive impairment and another with multiple diagnoses, including dysphagia, were affected. The facility's policy did not reflect updated practices, and staff reported a lack of training on tube feeding procedures.
Two residents requiring oxygen therapy did not receive care consistent with professional standards. One resident had outdated oxygen tubing, and another had unlabeled tubing, contrary to facility policy and physician orders. These deficiencies were confirmed by staff during a survey.
The facility failed to maintain accurate Controlled Substance Logs for four residents, with discrepancies in recorded medication quantities. An LPN could not explain the errors, and the DON acknowledged the issue, indicating plans to change the narcotic book system.
The facility failed to properly store and label medications and biologics, as expired Breeza bottles were found in stock and an opened Tuberculin Test vial lacked an opened date. An LPN and the DON acknowledged these oversights during interviews.
A long-term care facility failed to adhere to infection control protocols, as staff did not use proper PPE for residents on Enhanced Barrier Precautions (EBP). One resident receiving tube feeding was not provided care with the required gown, and another resident with a foot ulcer and on antibiotics was not placed on EBP. Staff acknowledged the oversights, and the Director of Nursing confirmed the expectations for EBP implementation.
The facility failed to prevent pressure injuries in two high-risk residents. One resident developed multiple infected pressure injuries due to a lack of routine skin assessments under a brace and ace bandage, leading to hospitalization. Another resident did not have a prescribed heel cup in place, as the care plan was not adjusted to reflect increased mobility and shoe-wearing. These deficiencies highlight a failure to adhere to pressure injury prevention protocols.
A resident experienced significant weight loss, but the facility failed to notify the physician as required by policy. Despite the resident's diagnoses of type 2 diabetes, moderate protein-calorie malnutrition, and a stage 4 pressure ulcer, there was no documentation indicating that the physician had been informed of the weight changes.
Unsanitary food handling and improper dry food storage
Penalty
Summary
Food was not prepared in a clean and sanitary environment and food was not properly stored. During observation, a Dietary Aide brought a dirty plate from the dining room back to the hot food service area and placed it on the hot service line window. Another staff member then placed more meat, vegetables, and noodles on that same plate before it was returned to the resident in the dining room. The Dietary Manager stated that the plate should never have been brought into the kitchen, that staff should have recognized it was dirty and taken it directly to the dirty dishes, and that a clean plate should have been used. Food storage practices were also not followed. A box of fortune cookies and a box of oyster crackers were observed on a shelf only 2 inches off the floor. In addition, a box of honey scooters, a bag of pancake mix, and 3 bags of cranberries were stored on the bottom shelf 4 inches off the floor. The facility policy stated that dry food must be stored at least 6 inches off the floor, and the Dietary Manager confirmed that all food items need to be at least 6 inches off the floor.
Infection Control Failures During Laundry Transport, Tube Feeding, and Medication Administration
Penalty
Summary
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. Survey observations showed clean laundry being transported from the laundry area through the facility to resident rooms on an uncovered rolling hanging cart. The housekeeping staff member stated clean linens and towels were not covered when delivered, and the Director of Nursing stated both linen and personal clothing should be covered when transported. During tube feeding care for a resident with stroke, hemiplegia, dysphagia, severe cognitive impairment, and dependence for all mobility and personal care, staff did not follow the facility’s Enhanced Barrier Precautions. A nurse entered the room multiple times to set up, flush, and disconnect the PEG tube while wearing gloves but no gown, and at times performed care without the required PPE. The nurse also moved between multiple resident rooms in the same scrubs and entered rooms on contact precautions without a gown. The nurse stated she did not think the resident was on any precautions and later acknowledged that Enhanced Barrier Precautions required a gown and that she did not follow that requirement. Medication administration and resident care observations also showed hand hygiene and PPE failures. One nurse administered medications to two residents on contact precautions without wearing PPE, and for one resident with a contact precaution sign on the door, the nurse did not perform hand hygiene before putting on gloves to administer eye drops. Another nurse was observed touching a floor, multiple PPE carts, and then putting on gloves without hand hygiene before entering a resident’s room. The same nurse removed a contaminated dressing, did not perform hand hygiene before changing gloves, and continued wound and PEG tube care with contaminated hands. The DON confirmed that hand hygiene should have been performed before and after glove use, between dirty and clean tasks, and during care of residents on contact precautions.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility did not ensure that multiple residents receiving psychotropic medications were free from unnecessary drugs. Review of records and interviews showed that R2, R8, R3, and R4 were each receiving psychotropic medications without adequate indication, diagnosis, or supporting documentation in the medical record. The facility policy stated psychotropic medications are to be used only when clinically indicated, with gradual dose reductions and non-pharmacological interventions attempted unless contraindicated. R2, who was admitted with diagnoses including unspecified dementia without behavioral disturbance and severe cognitive impairment, was prescribed quetiapine 25 mg daily for dementia-related indications. The record showed no documented behaviors such as delirium, paranoia, hallucinations, mood swings, agitation, or wandering during the reviewed period, and no gradual dose reduction was attempted or documented as clinically contraindicated. The CNO stated the resident had been admitted with the medication order and acknowledged that dementia was not an appropriate indication for use. R8, who had diagnoses including anxiety disorder, major depressive disorder, and insomnia, was given diphenhydramine-APAP daily for insomnia despite sleep monitoring showing an average of 7 hours of sleep per night before the medication was started and no sleep assessment being documented. R8 also received lorazepam on multiple occasions for anxiety/terminal restlessness, but the record contained no documented behaviors before administration. The DON and CNO were unable to provide adequate documentation supporting the scheduled use of diphenhydramine-APAP or the need for lorazepam based on observed behaviors. R3, who had diagnoses including paranoid schizophrenia and drug-induced subacute dyskinesia, was prescribed sertraline and risperidone, but the record contained no documented psychiatric consults or assessments since admission and no documented behaviors supporting the antipsychotic use. R4, who had diagnoses including major depression, single episode, was prescribed duloxetine for depression, but the surveyor found no documentation of behaviors supporting the diagnosis beyond depression and the DON was unable to find documentation of behaviors or another diagnosis supporting the medication. Behavior monitoring for R4 was incomplete and often did not document the specific behavior when a behavior was marked as present.
Missing transfer, bed-hold, and Ombudsman notifications
Penalty
Summary
The facility did not ensure that residents transferred to the hospital or discharged received written transfer notices that included the reason for transfer, the location of transfer, appeal rights, and the name, address, email, and telephone number of the Office of the State Long-Term Care Ombudsman. The facility also did not maintain evidence that the Ombudsman was notified of resident transfers or discharges. In addition, residents did not consistently receive written information about the duration of the bed-hold policy, the reserve bed payment policy, and the right to return to the facility. R42, who had diagnoses including epilepsy, diabetes, and chronic renal failure/end stage renal disease, was transferred to the hospital twice for altered mental status, lethargy, and weakness. One transfer was for evaluation after a head CT, chest x-ray, and urinalysis in the emergency room, and the other was to a larger city hospital at the family’s request, where the resident was hospitalized for pneumonia, COVID, and UTI. No written bed-hold notice, transfer notice, or Ombudsman notification was documented for either transfer. R4, who had diagnoses including type 2 diabetes mellitus, chronic atrial fibrillation, history of TIA, acute kidney failure, debility, and bilateral hearing loss, had an MDS documenting absent hearing, unclear and slurred speech, and limited understanding of conversation. R4 was transferred to the hospital for decreased interactivity, weakness, decline, and later chest pressure with NSTEMI, but written transfer notices and bed-hold notices were not consistently documented, and the Ombudsman was not notified. R31 was transferred for decreased urinary output and new onset urinary tract pain, and R44 was transferred for altered mental status and later left the hospital AMA without returning; for both residents, no written transfer notice, bed-hold notice, or Ombudsman notification was documented.
Failure to Acknowledge Pharmacy Medication Review Recommendations
Penalty
Summary
The facility did not ensure that monthly medication regimen reviews were acted upon and that pharmacy recommendations were acknowledged by a physician for 3 of 5 residents reviewed. The report states that the pharmacist was to communicate medication irregularities in writing within 10 working days, and facility staff were to act on recommendations according to policy. Surveyor review and interviews showed that provider responses were not documented for several pharmacy recommendations, including recommendations that were repeated in monthly reviews. For one resident with anxiety disorder, major depressive disorder, insomnia, and multiple psychoactive medications, the pharmacist documented that recent falls may have been contributed to by Benadryl, lorazepam, morphine, and citalopram. The resident had multiple unwitnessed falls, and the recommendation to evaluate these medications as possible contributors to falls had no documented provider response. The DON stated the recommendation had been forwarded but confirmed the provider had not responded and that it should have been reviewed more quickly because of the fall risk. For another resident with paranoid schizophrenia and drug-induced subacute dyskinesia, the pharmacist recommended a gradual dose reduction of risperidone and sertraline, but the recommendation was not addressed for months and repeated monthly through December without provider response. For a third resident with diabetes, chronic atrial fibrillation, TIA history, acute kidney failure, hearing loss, and major depression, the pharmacist repeatedly recommended a gradual dose reduction of duloxetine, but the physician response forms were blank or unsigned and no GDR was attempted. The DON stated the GDR recommendation for the schizophrenia resident should have been addressed.
Failure to Complete PASRR Level II Screening After Exemption Period
Penalty
Summary
The facility did not complete a PASRR Level II screen for a resident admitted with a diagnosis of paranoid schizophrenia who was receiving psychotropic medications, including Sertraline and Risperidone, to treat symptoms of a major mental disorder. A Level I PASRR completed on 01/02/25 identified that the resident had a serious mental illness and was receiving psychotropic medications, and it also noted a hospital discharge exemption with a 30-day maximum stay and stated the resident was not to remain in the facility beyond the permitted exemption period. The resident remained in the facility after the exemption period ended, but no additional PASRR screenings were completed. During interview on 01/13/26, the Social Services staff member stated he was not in the role at the time and could not explain why another PASRR was not completed after the 30-day exemption period, and stated that it should have been completed.
Failure to Provide Timely Transfer Due to Unavailable Lift Slings
Penalty
Summary
The facility failed to provide necessary care to ensure a resident's activities of daily living (ADLs) needs were met, specifically regarding timely transfers out of bed. According to facility policy, care should be provided in a safe, appropriate, and timely manner in accordance with the resident's care plan. The resident in question had a history of dementia, chronic pain, anemia, and mobility issues, and was dependent on staff for transfers, requiring a full body lift with two staff members. On the day of the incident, the resident was placed back in bed around 1:00 PM after their sling became soiled and was put in the wash. Staff informed the resident's responsible party that the slings were unavailable as they were being washed, and the resident remained in bed for the rest of the evening, despite requests to be transferred out of bed. Interviews with staff confirmed that the resident was not transferred out of bed due to the lack of clean slings for the mechanical lift, and this was communicated during shift changes. The Director of Nursing and the Administrator both stated that residents dependent on staff for transfers should be assisted out of bed as per their care plan and requests. The Director of Nursing also noted that all slings should not have been washed at the same time, which contributed to the unavailability of necessary equipment and the failure to meet the resident's care needs.
Failure to Assess and Monitor Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with a history of substance use disorder (SUD). Despite the facility's policy requiring assessment, monitoring, and care planning for residents with SUD, the resident's care plans did not address concerns or monitoring related to substance use. The care plans focused on adjustment issues and behavior management but omitted specific interventions or monitoring for SUD, even though the resident had diagnoses including methamphetamine use disorder and alcohol use disorder in remission. Physician orders since admission also did not include any monitoring or assessment for substance use risk as outlined in facility policy. An incident occurred in which the resident was found to have used methamphetamine during their stay. Following this, staff education was provided, but it did not include guidance on assessing, monitoring, or identifying substance use. Interviews with staff revealed a lack of knowledge regarding specific signs of methamphetamine use and an absence of documentation supporting staff training on identifying, assessing, and monitoring for substance abuse in residents with a history of SUD. This demonstrates that the facility did not implement its own policy requirements for residents with SUD, resulting in a failure to ensure the resident's highest practicable mental and psychosocial well-being.
Failure to Administer Correct Anticoagulation Therapy
Penalty
Summary
The facility failed to provide appropriate anticoagulation therapy for two residents, leading to significant medication errors. For one resident, the facility did not verify and transcribe a new physician order that increased the Warfarin dose. This oversight resulted in the resident not receiving the correct Warfarin dose for several days, which led to the resident being sent to the Emergency Department. The resident required intravenous heparin and Lovenox bridging to achieve therapeutic anticoagulation levels due to the missed doses. The resident, who had a history of heart failure, a prosthetic heart valve, and other significant health conditions, was admitted to the facility with specific Warfarin dosing instructions. However, the facility failed to update the Medication Administration Record (MAR) with the new Warfarin order, resulting in missed doses over several days. The resident's condition deteriorated, leading to a transfer to a higher level of care hospital with a diagnosis of transient ischemic attack (TIA) and other complications. In another instance, the facility did not properly verify and transcribe new Warfarin orders for a second resident. The Anticoagulant Binder at the nurses' station showed incomplete documentation, with missing nurse signatures for validation of new physician orders. This lack of proper documentation and verification led to the failure to update the resident's MAR with the new Warfarin dosing schedule, indicating a systemic issue in the facility's process for managing anticoagulation therapy.
Medication Administration Lapse for Resident
Penalty
Summary
The facility failed to ensure medications were administered safely and effectively for one resident, identified as R2. During a medication pass, the Director of Nursing (DON) left R2's medications unattended on a tray table, despite a facility assessment indicating R2 was incapable of self-administering medications. R2, who has a history of paranoid schizophrenia, major depressive disorder, anxiety disorder, chronic kidney disease, and chronic respiratory failure, self-administered the medications while the DON was out of the room. Upon returning, the DON attempted to administer the medications again, only to be informed by R2 that they had already been taken. The facility's policy on self-administration of medications requires an assessment to determine a resident's capability to self-administer, and medications should not be left unattended with residents who have not passed this assessment. Despite R2's cognitive intactness as indicated by a BIMS score of 15 out of 15, the self-administration assessment showed R2 needed assistance with medication administration. The DON acknowledged that medications should not be left with residents who did not pass the self-administration assessment, indicating a lapse in following the facility's medication administration protocols.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely and in accordance with accepted professional practices. During an observation, a surveyor noted that one of the two medication carts was left unlocked and unattended outside a resident's room in the 300 hall. This occurred despite the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments, such as medication carts, to ensure security. The incident involved a Licensed Practical Nurse (LPN) who left the medication cart unlocked while attending to a resident in their room. The LPN admitted to the surveyor that the cart is usually locked when unattended but failed to do so on this occasion. The Director of Nursing (DON) confirmed that the expectation is for all medication carts to be locked when not attended, indicating a lapse in adherence to the facility's medication storage policy.
Lack of Qualified Dietary Manager and Full-Time Dietician
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which could potentially affect all 31 residents residing in the facility. The Dietary Manager (DM) had been in the position for approximately two weeks and had not started any classes to become a Certified Dietary Manager. During a kitchen tour, the DM admitted to not holding any certifications required for the role and was unsure if they were enrolled in a training program. The Nursing Home Administrator (NHA) believed the DM was enrolled in a Certified Dietary Manager program, but the enrollment documentation was only provided on the day of the survey. Additionally, the facility did not have a full-time Registered Dietician, as the dietician was present only one day a week and available by phone, with additional support from a Certified Dietary Manager from a sister facility one day per week.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the preparation of food in a clean and sanitary environment, potentially affecting all 31 residents. During a kitchen tour, it was observed that staff did not consistently date or label food items when opened, as required by the facility's policy. Containers of juice and milk were found without dates, which is necessary for determining when they should be discarded. Additionally, staff did not consistently test or document the parts per million (PPM) of the quaternary sanitizing solution, with several dates missing from the test log. The facility also failed to consistently document refrigerator and freezer temperatures, which are crucial for storing potentially hazardous foods at safe temperatures. The temperature logs for December had numerous blanks, indicating non-compliance with the facility's policy. Furthermore, dish machine temperatures were not consistently recorded, with many missing entries on the temperature log, which is essential for ensuring dishes and utensils are properly sanitized. Staff were observed touching ready-to-eat food with contaminated gloves, contrary to the facility's glove usage policy. During meal service, a staff member used the same gloves to handle various surfaces and then touched food items, potentially contaminating them. Additionally, trays delivered to resident rooms contained uncovered food items, violating the facility's policy that requires food to be covered during transport through patient care and public areas.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper personal protective equipment (PPE) procedures during wound care for a resident on Enhanced Barrier Precautions (EBP). A Registered Nurse (RN) was observed providing wound care to a resident without sanitizing bandage scissors and a marking pen before and after use. The RN also reached into their uniform pocket with gloves that had been used for wound care, potentially contaminating the uniform. These actions were contrary to the Centers for Disease Control and Prevention (CDC) guidelines, which emphasize the importance of cleaning and disinfecting wound care equipment between patients to prevent cross-contamination. During the observation, the RN initially used hand sanitizer and donned a gown and gloves before entering the resident's room. However, the RN failed to sanitize the scissors after using them to cut strips of tape and again after cutting a piece of dressing for the wound. The RN also used a marker to date the dressing without sanitizing it before or after use. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the RN did not follow correct infection control procedures, acknowledging that the RN should not have reached into their uniform pocket with gloves on and should have sanitized the equipment used during wound care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was posted at the beginning of each shift, as required by federal regulations. This deficiency was observed during a survey when the surveyor was unable to locate the daily nurse staffing posting on two consecutive days. On the first day, the Nursing Home Administrator (NHA), who was new to the position, was unaware of the location of the staffing postings and did not provide further information. On the second day, the Assistant Director of Nursing (ADON) revealed that the previous NHA was responsible for the postings and had not communicated this duty to anyone else upon their departure. As a result, the daily nurse staffing data had not been posted since October of that year, affecting all 31 residents in the facility.
Inadequate Supervision Leads to Multiple Elopements
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a known history of elopement. The resident, who had previously eloped from a hospital, was admitted to the facility under emergency protective placement. Despite being identified as an elopement risk, the resident managed to elope from the facility on three separate occasions. The first elopement occurred shortly after admission, and the resident was found outside the facility by staff. The second elopement involved the resident being missing for 2.5 hours, requiring police intervention and a K9 search to locate them. The third elopement was particularly dangerous, as the resident traveled 1.4 miles through busy traffic and attempted to jump off a bridge. The facility's policies on elopement and elopement management were not effectively implemented. The resident's elopement risk was not adequately addressed in their care plan, and the interventions, such as the placement of a wanderguard, were delayed. The facility also failed to document the first and second elopements in the resident's medical record and did not increase supervision or implement additional interventions after these incidents. The staff on duty during these events were not adequately trained or prepared to handle the situation, as evidenced by the agency nurse's lack of knowledge in operating the facility's alarm system. The facility's inaction and lack of proper supervision created a situation of immediate jeopardy, as the resident's safety was compromised multiple times. The facility did not have sufficient staff to provide the necessary supervision, and the interventions that were in place, such as 15-minute checks, proved ineffective. The facility's failure to act promptly and appropriately in response to the resident's elopement risk led to repeated incidents that endangered the resident's well-being.
Removal Plan
- All staff education included supervision when a resident displays exit seeking behavior.
- Resident assisted to a common area.
- Resident engaged in activities of interest.
- Resident provided psychosocial support.
- Resident family contacted and included if able.
- Increased visits from facility managers.
- Staff coordination on who will be providing the increased supervision and for how long and when to provide relief.
- If resident behaviors continue, increased 1:1 support may be needed per staff discussion which includes DON/NHA/designee.
- Wanderguard does not replace supervision. Staff should be proactive and increase supervision as needed when resident displays exit seeking behavior.
- Staff should contact DON/NHA/designee for additional support and guidance.
- All elopement risk assessments were updated.
- All elopement residents' care plans were updated.
Deficiency in Food Handling and Temperature Logging
Penalty
Summary
The facility failed to ensure the safety of food handling in accordance with professional standards for food service safety. During an inspection, it was observed that milk and juice containers in the walk-in cooler were opened but not labeled with an opened date or use-by date. This oversight was contrary to the facility's policy, which requires all refrigerated and prepared food to be covered, labeled, and dated with a use-by date that is a maximum of seven days from the date of preparation. The Dietary Manager confirmed that the expectation was for opened milk and juice to be labeled with a use-by date using stickers provided by the facility. Additionally, the facility did not maintain complete daily temperature logs for refrigerators and freezers, as required by their policy. The surveyor noted missing entries for freezer temperatures on specific dates, which could potentially lead to foodborne illness. The Dietary Manager acknowledged that the expectation was for temperatures to be recorded twice daily, which was not being adhered to. This deficiency had the potential to affect 31 out of 32 residents who consume food orally.
Failure to Report Resident Elopements and Misconduct
Penalty
Summary
The facility failed to report an incident of potential misconduct involving a resident's elopements to the state agency immediately upon learning of the incident and did not submit the required 5-day investigation report. The deficiency involved a resident who was admitted to the facility under emergency protective placement with a history of encephalopathy, amnesia, disorientation, and other medical conditions. The resident eloped from the facility three times on the same day, with the second and third elopements involving law enforcement and emergency medical intervention. During the first elopement, the resident exited through an employee door, triggering an alarm, and was redirected back into the facility by a CNA. Shortly after, the resident eloped again through an emergency door and was found by law enforcement two blocks away. The third elopement involved the resident attempting to jump off a bridge, requiring intervention by staff and a civilian. Despite these serious incidents, the facility did not report them to the Department of Quality Assurance (DQA) as required, and the Chief Nursing Officer and Nursing Home Administrator were unaware of the reason for the lack of reporting.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a significant change in physical condition and cognition. The resident, who had a history of heart attack, COPD, type 2 diabetes mellitus, obesity, and chronic kidney disease, was initially assessed with intact cognition and required substantial assistance with daily activities. However, the resident began experiencing hallucinations, was hospitalized for respiratory failure, and upon readmission, continued to exhibit delusions and a decline in cognitive and physical condition. Despite these changes, the facility did not complete a SCSA as required by their policy. The resident's condition continued to deteriorate, with progress notes indicating increased carbon dioxide levels, hallucinations, and the development of pressure ulcers. The facility's staff, including the Nursing Home Administrator, acknowledged that the resident met the criteria for a SCSA, but it had not been completed timely. The facility was in the process of obtaining physician signatures to determine the resident's capacity to make healthcare decisions and had scheduled a psychiatric evaluation. The deficiency was identified during a surveyor's observation and interviews with facility staff, who confirmed the resident's refusal to reposition in bed and complete prescribed treatments.
Failure to Follow Hospital Discharge Orders and Assess Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had a history of respiratory issues including obstructive sleep apnea and chronic obstructive pulmonary disease, was discharged from the hospital with specific instructions for follow-up care. These instructions included laboratory testing five days post-discharge and a sleep medicine evaluation due to the resident's refusal to use a CPAP device. However, the facility did not adhere to these discharge orders, as the laboratory tests were conducted 22 days after discharge, and the sleep study was scheduled much later. Additionally, the resident experienced a change in condition, including hallucinations and physical decline, which the facility did not comprehensively assess. Despite the resident's intact cognition as indicated by a BIMS score of 15/15, the facility failed to address the resident's ongoing issues promptly. The lack of timely follow-up on the hospital's discharge instructions and the inadequate assessment of the resident's change in condition contributed to the deficiency identified by the surveyors.
Failure to Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to formulate and maintain an advance directive for Resident 236, who was admitted to the facility and was capable of understanding and communicating their wishes. During a survey, it was found that there were no orders for a Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) status in the resident's hard charts or electronic records. The surveyor could not locate any provider orders related to advanced directives for this resident. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Medical Records (MR) personnel, and the Chief Nursing Officer (CNO), revealed that the expected documentation for advanced directives was missing. The LPN indicated that such information should be available in the electronic record and the Post Book organized by room location. However, neither the hard charts nor the books at the nurses' station contained the necessary documentation. The CNO confirmed that they also could not find the required documentation, which should have included doctor orders, face sheet documentation, and a Physician Orders for Scope of Treatment (POST) sheet.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to consult with a physician regarding a significant weight gain experienced by a resident, identified as R26. The facility's policy mandates physician notification for significant weight changes, defined as a gain or loss of 5% or more in the past 30 days. R26, who has Alzheimer's disease, hypertension, and chronic pain, showed a weight increase from 178 pounds to 191.4 pounds between August 2, 2024, and September 4, 2024, representing a 7.2% gain in one month. Despite this, there was no documentation indicating that the primary care provider (PCP) was informed of this significant change. The facility was aware of the weight changes, as the information was recorded in their system. However, the Assistant Director of Nursing (ADON) confirmed that the PCP was not updated about the weight gain after a five-day period of daily weight monitoring, which was ordered due to discrepancies in recorded weights. The failure to notify the PCP occurred despite the facility's policy and the physician's order for weekly weight checks. The PCP was eventually informed on October 7, 2024, but this was after the surveyor's review and interview with the ADON.
Failure to Justify and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat medical symptoms. The resident, who had a history of paralysis and severe cognitive impairment following a stroke, was observed with a lap belt in his wheelchair. There was no physician order, medical symptom justification, or assessment documented for the use of this restraint. The resident's care plan did not include the use of a restraint, and the facility's policy on restraint management was not followed. Interviews with the resident's family member and facility staff revealed that the lap belt was used out of habit, as it came with the wheelchair, and not due to a medical necessity. The resident was unable to remove the lap belt independently, indicating it functioned as a restraint. The facility's Assistant Director of Nursing confirmed the lack of documentation supporting the restraint's use and subsequently removed it, acknowledging that the resident did not require it.
Failure to Provide Written Notices of Transfer for Hospitalized Residents
Penalty
Summary
The facility failed to provide timely written notices of transfer to three residents who were hospitalized, as required by regulations. Resident 11 and Resident 28 were both hospitalized on separate occasions but did not receive written notices of their transfers. Similarly, Resident 20 experienced a change in condition and was transferred to the emergency room, later being admitted to the hospital with a complicated urinary tract infection and a chronic indwelling Foley catheter. Despite this, no written notice of transfer was provided to Resident 20 or their representative. During an interview, Medical Records C confirmed that the facility lacked a process for issuing written notices of transfer when residents are hospitalized.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that two residents, identified as R28 and R20, received written notification of the facility's bed hold policy when they were transferred to the hospital. According to the facility's policy, when a resident is transferred to a hospital or requests a therapeutic leave, the center is required to provide written notice to the resident or their representative regarding the bed hold rights and policy. This policy states that a resident's bed will be held automatically for 15 days at 100% of the current daily rate unless otherwise notified. However, during the survey, it was found that R28, who was his own decision maker, was hospitalized twice, and there was no evidence that he was notified of the bed hold policy during these hospitalizations. Similarly, R20 experienced a change in condition and was transferred to the emergency room, later being admitted to the hospital with a complicated urinary tract infection. The surveyor reviewed R20's records and found no evidence that R20's representative was notified of the bed hold policy at the time of hospitalization. The Social Services Director was interviewed and reported being unable to locate the bed hold notifications for the hospitalizations of both R28 and R20, indicating a lapse in the facility's adherence to its own policy.
Failure to Monitor and Communicate Significant Weight Gain
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status for a resident, identified as R26, who experienced a significant weight gain. The facility's policy on weight management requires regular monitoring of residents' nutritional status, including obtaining routine weights. However, R26, who has Alzheimer's disease, hypertension, and chronic pain, experienced a weight gain of 7.2% in one month, which was not on a physician-prescribed weight gain regimen. The facility's records showed that R26's weight increased from 178.6 lbs to 191.4 lbs over a period, indicating a significant change that should have been addressed according to the facility's guidelines. Despite the facility's awareness of the weight changes through their computer system, the Medical Doctor was not updated regarding the weight gain after a five-day period of daily weight monitoring. The facility's policy requires that significant weight changes be communicated to the attending physician and documented in the resident's progress notes. However, this communication did not occur, as confirmed by the Assistant Director of Nursing during an interview. This lack of communication and failure to follow the facility's weight management policy contributed to the deficiency in maintaining the resident's nutritional status.
Deficiency in Feeding Tube Management and Staff Training
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received appropriate treatment and services to prevent complications and restore oral eating skills. Specifically, the facility did not adhere to current standards for checking feeding tube placement for two residents. The facility's policy, dated April 2024, required licensed nurses to verify tube placement before feedings and medication administration. However, the policy did not reflect updated standards, as it still endorsed the auscultation method, which is no longer recommended. Resident R24, who had multiple diagnoses including cognitive impairment, was observed having their feeding tube placement checked using the auscultation method by a registered nurse, contrary to current best practices. The Director of Nursing was unaware of the recent policy change, indicating a lack of communication and training regarding updated procedures. Similarly, Resident R13, with diagnoses including moderate protein-calorie malnutrition and dysphagia, also had their feeding tube placement checked using the auscultation method by an LPN. The LPN did not check for residual fluid or assess for gastric discomfort before administering medications, which is a deviation from proper protocol. The LPN reported not receiving any training on tube feeding from the facility since starting their position, highlighting a gap in staff education and training. These deficiencies indicate a systemic issue in the facility's adherence to updated standards and staff training regarding feeding tube management.
Failure to Adhere to Oxygen Tubing Change Protocols
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents requiring oxygen therapy. Resident 11, who has a history of chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed with oxygen tubing dated several months prior, despite physician orders to change the tubing weekly. The facility's policy also mandates weekly changes, yet the treatment administration record falsely indicated compliance with this requirement. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the outdated tubing and proceeded to change it immediately. Similarly, Resident 29 was found using unlabeled oxygen tubing, contrary to the facility's expectations for labeling during each change. The Assistant Director of Nursing (ADON) was in the process of replacing the tubing when questioned by the surveyor, admitting the oversight. These observations highlight a failure in adhering to prescribed respiratory care protocols, as evidenced by the outdated and unlabeled oxygen tubing for both residents.
Inaccurate Controlled Substance Logs in LTC Facility
Penalty
Summary
The facility failed to maintain an accurate and reliable system for accounting the receipt, usage, disposition, and reconciliation of controlled medications for four residents. The Controlled Substance Logs were found to be inaccurate, with discrepancies in the recorded quantities of medications before and after administration. For instance, the logs showed incorrect remaining quantities after doses were administered to residents, indicating a lack of precise record-keeping. The facility's policy on Controlled Substance Management, which aims to prevent loss, diversion, or accidental exposure, was not effectively implemented, as evidenced by the inaccuracies in the logs. During interviews, a Licensed Practical Nurse (LPN) was unable to explain the discrepancies or identify the initials responsible for the errors. The Director of Nursing (DON) acknowledged the inaccuracies and expressed an intention to change the current system of narcotic books. The deficiencies were identified through a combination of interviews and record reviews, highlighting a systemic issue in the facility's management of controlled substances.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to currently accepted professional principles. During an inspection, it was observed that expired medications and biologics were not removed from the stock supply in the medication storage room. Specifically, two bottles of Breeza, a beverage used for neutral abdominal imaging, were found with expiration dates of 9/22, indicating they were expired and still present in the general stock. Additionally, an opened multidose vial of Tuberculin Test, Tubersol Injection, was found without an opened date written on it, contrary to the facility's guidelines which require such vials to be dated when opened and discarded after 30 days. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed the oversight. The LPN acknowledged that the expired Breeza bottles were "really old" and should have been discarded, and subsequently removed them from the shelf. The LPN also admitted that the Tuberculin Test vial should have been marked with the date it was opened. The DON agreed with these assessments, acknowledging that the expired biologics should have been discarded and the opened vial should have been properly dated.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) when providing care to residents. In the first instance, a Registered Nurse (RN) did not wear a gown while performing a tube feeding for a resident on EBP, despite the presence of signage indicating the requirement for gown and gloves. The RN acknowledged the oversight during an interview, admitting that they were aware of the protocol but failed to follow it at that time. The Chief Nursing Officer and Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves during such procedures. In another instance, a resident with a foot ulcer and on antibiotics for osteomyelitis was not placed on EBP, despite having open wounds and being on antibiotic treatment. A Licensed Practical Nurse (LPN) acknowledged that the resident should have been on EBP and planned to implement it after the surveyor's inquiry. The Director of Nursing confirmed that it was the nurses' responsibility to place residents on EBP when necessary, and that the resident's condition warranted such precautions.
Failure to Prevent Pressure Injuries in High-Risk Residents
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for two residents at high risk. One resident was admitted with a brace and ace bandage on her leg and was identified as being at risk for pressure injuries. However, the facility did not develop a care plan or routinely assess the skin under the brace and ace bandage, leading to multiple pressure injuries. These injuries became infected, requiring hospitalization and surgical intervention. The facility's policy on pressure injury prevention was not followed, as the skin under medical devices was not inspected as required. The resident's care plan did not include interventions for skin care or pressure injury prevention, and there was a lack of documentation regarding skin assessments. Despite having a high Braden score indicating risk, no pressure-reducing devices or nutritional interventions were utilized. The facility also failed to clarify discharge instructions regarding the removal of the leg brace, contributing to the development of pressure injuries. Another resident, who was at risk for pressure injuries due to decreased mobility and muscle weakness, did not have the prescribed heel cup in place as required. The facility did not adjust the care plan to reflect the resident's increased mobility and shoe-wearing, leading to a failure in following the plan of care. This oversight was discovered during a surveyor's review, indicating a lack of adherence to the prescribed interventions for pressure injury prevention.
Removal Plan
- Provide education to all nursing staff on skin policies and procedures, including admission assessments, and implementing orders to check skin under medical devices daily for signs of pressure related injuries, and timely updates with new skin issues/breakdown with orders obtained and care plans updated.
- Provide education to the Interdisciplinary Team (IDT) on new admission review to ensure skin assessments are completed and schedule is in place in the treatment administration record (TAR) to check under any medical device daily for signs of pressure related injuries.
- Provide education to all nursing staff, minimum data set (MDS) coordinator, and IDT on ensuring care plans with specific interventions are implemented for all residents at risk of developing pressure injuries. Education including review of care plans, evaluations of effectiveness of interventions, and addition of new interventions if needed.
- Perform a facility-wide skin sweep to ensure all residents at risk for pressure injuries have care planned interventions, all current skin conditions are documented and on the weekly wound tracking document, and any new skin concerns are identified, and the physician and resident's power of attorney (POA) if applicable are updated with orders obtained and care plan updates are made.
- Director of Nursing (DON)/designee will conduct new admission audits daily to ensure orders are in place to check under medical devices for those utilizing.
- DON designee will conduct weekly audits of resident care plans to ensure interventions are in place and effective for those at risk for pressure injuries.
- Medical devices added to IDT daily clinical board to ensure orders in place for skin monitoring.
- The results of all audits will be brought to monthly quality assurance performance improvement (QAPI) meeting to determine effectiveness and if additional audits or education are needed.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician about significant weight loss, which is a violation of their policy. The policy requires the director of nursing or designee to notify the attending physician of significant weight changes and document it in the resident's progress notes. The resident in question, who has diagnoses including type 2 diabetes, moderate protein-calorie malnutrition, and a stage 4 pressure ulcer, experienced a significant weight loss from 258.2 pounds on admission to 171 pounds over several months. Despite this, there was no documentation indicating that the physician had been notified of the weight loss. The surveyor reviewed the resident's medical chart and found no notifications made to the resident's physician regarding the significant weight variance. When the surveyor requested any medical doctor notifications from the Nursing Home Administrator, the Corporate Registered Nurse confirmed that there was no indication that the physician had been notified about the weight loss. This oversight had the potential to affect the resident's health and well-being, as timely medical intervention was not sought for the significant weight loss.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Black River Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine View Care Center | 0.4 mi | ★★★★★ | 27 | 0 |
| Grand View Care Ctr | 18.4 mi | ★★★★★ | 0 | 0 |
| Pigeon Falls Hcc | 19.2 mi | ★★★★★ | 0 | 0 |
| Trempealeau Cty Hcc Imd | 23 mi | ★★★★★ | 2 | 0 |
| Rolling Hills Rehab Ctr | 24.1 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.