Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Bloomer during CMS and state inspections, most recent first.
Surveyors observed unsafe food handling practices, including staff failing to wash hands before gloving and handling food, a DM washing hands for only a few seconds, and food being served without temperatures being taken and recorded as required. Surveyors also found delayed storage of delivered cold and frozen foods, incomplete refrigerator/freezer, ice scoop, dishwasher, and tray line logs, an undated open gallon of milk, and a staff member distributing food without a beard restraint while touching ready-to-eat foods with contaminated gloves.
Infection Control: Improper PPE Use in Laundry Services. The facility failed to maintain an infection prevention and control program when a laundry aide handled soiled and clean linens without the required barrier attire. The aide stated she usually wore gloves only, and the surveyor observed her folding towels and a mechanical lift sling, moving clean whites, and sorting dirty towels and linen without a gown/apron or other barrier between her clothing and the items, despite facility policy requiring PPE for sorting and washing linens.
Incomplete transfer notices and missing bed hold and ombudsman notifications. The facility failed to provide complete written transfer/discharge notices with required details for multiple residents, and some residents did not receive bed hold notices. Surveyors found missing reasons, dates, names, and locations on transfer forms, no notice for one transfer, and no evidence that the Ombudsman was notified for one resident. Several affected residents were cognitively intact, and two had significant medical histories including ESRD, CVA-related hemiplegia, aphasia, CKD, DM, and anemia.
PASARR screening was not completed appropriately for one resident with schizophrenia and bipolar disorder. The resident’s PASARR Level I showed a major mental disorder, symptoms suggesting major mental illness, psychotropic medication use, and a history of ID, but it also listed a hospital discharge exemption with no Level II required. The MDS Nurse said she relied on SS for the Level I, and SS later confirmed the resident was past the 30-day exemption period after the planned group home placement fell through.
A resident with PTSD, depression, and other mental health diagnoses had a trauma-informed assessment that identified a near-drowning experience and fear of showering, but the care plan did not include individualized trigger-based interventions from that assessment. The plan addressed behavior problems and stress reduction, yet surveyors could not find the resident’s trauma triggers documented in the care plan.
Unsecured storage of controlled medication in medication room refrigerator. Surveyors observed an unlocked medication room refrigerator containing residents’ extra unopened labeled medications and a stock supply box of liquid Ativan. An RN stated the refrigerator should have been locked, and the DCS confirmed Ativan was expected to be double locked, with the medication room door counting as one lock; the ADON identified the box as Ativan, and the DCS stated a zip tie would not count as a second lock.
Surveyors identified multiple deficiencies in food handling and sanitation, including a dietary aide failing to allow a thermometer probe to air dry after alcohol sanitization before checking beverage temperatures, improper labeling and storage of resident food items brought from outside, and a dietary aide handling clean dishes with a soiled shirt and putting away wet dishware. The dietary manager confirmed these practices did not meet facility policy or expectations.
Staff failed to consistently follow infection control protocols, including timely implementation of contact precautions for residents with GI symptoms, proper use of PPE, and hand hygiene. CNAs were observed entering rooms without required PPE, wearing masks incorrectly during outbreaks, and handling soiled linens without gloves or proper bagging, contrary to facility policy. Interviews confirmed staff were aware of expectations but did not consistently adhere to them, resulting in a breakdown of infection prevention measures.
A facility failed to report an allegation of exploitation involving a resident with cerebral palsy and epilepsy. A CNA took a picture of the resident's private area with a personal cell phone to show another staff member that the wrong cream was applied. The incident was reported internally, and the CNA deleted the picture, but the Nursing Home Administrator did not report it to the State Agency, citing a misinterpretation of the regulation.
A resident with depression, anxiety, and PTSD had a completed PASARR level 2 screen, but the MDS assessment was inaccurately coded to indicate that no such screen had been done. This discrepancy was confirmed by the DON during a surveyor interview.
A resident with PTSD had a care plan that did not include interventions for known triggers, specifically loud noises, despite this being identified in a trauma-informed assessment. Staff, including CNAs and LPNs, were unaware of the resident's PTSD diagnosis or related care needs, and the DON acknowledged the care plan lacked clarity regarding these issues.
A resident experienced a fall during a mechanical lift transfer due to improper sling placement by CNAs, highlighting inadequate supervision and training. The resident, admitted for rehabilitation after a below-knee amputation, required assistance with transfers. The incident, which did not result in injury, exposed a deficiency in staff training, placing other residents at risk until comprehensive training was scheduled 25 days later.
Unsafe Food Handling and Incomplete Temperature Monitoring
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in a sanitary manner. During kitchen observation, surveyors saw multiple staff members fail to perform hand hygiene before putting on gloves and before handling food. One staff member entered the kitchen, touched surfaces, and began plating cake without washing hands. The same staff member later put on gloves without hand hygiene, handled a hamburger from the freezer, removed gloves, and did not wash hands. Another staff member returned to the kitchen, did not perform hand hygiene, put on gloves, and made a tuna sandwich. The Dietary Manager also entered the kitchen without washing hands and was observed washing hands for only about 8 to 10 seconds on separate occasions. Staff interviews confirmed expectations for handwashing when entering the kitchen, touching doorknobs, changing tasks, and before putting on gloves. Food temperatures were not consistently taken and recorded prior to service. Surveyors observed food being removed from the oven and placed on the stove without temperatures being taken at the time it came out of the oven. Food was served without temperatures being checked before service. One staff member took temperatures of some items, but did not write them down, and later stated temperatures were written on a note pad instead of directly on the temperature log. Surveyors reviewed the current week’s temperature log and found it incomplete, and the facility did not provide the prior month’s logs when requested. The Dietary Manager stated food should be temped and written on the form right away and that food should be temped when it comes out of the oven and before serving. The facility also did not timely store delivered cold and frozen foods. Surveyors observed boxes stacked in front of the freezer and walk-in cooler, with delivery items still on the floor after the delivery had arrived earlier that morning. Frozen bread was found in a box and was not frozen solid. Temperatures of items left out for storage were above safe refrigeration levels, including chocolate milk at 43.5 degrees Fahrenheit, milk at 46.6 degrees Fahrenheit, and liquid eggs at 48.4 degrees Fahrenheit. In addition, surveyors found incomplete refrigerator/freezer logs, incomplete ice scoop cleaning logs, incomplete dishwasher temperature logs, an open gallon of milk without a date, incomplete tray line food temperature audits, and a staff member distributing food without a beard restraint while touching ready-to-eat foods with contaminated gloves.
Infection Control: Improper PPE Use in Laundry Services
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because 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. The deficiency involved laundry services and the handling of soiled linens and laundry, with the facility failing to ensure staff wore appropriate PPE while handling dirty items. Facility policy titled "Handling Linens and Laundry," dated January 2026, stated that employees sorting or washing linens shall wear a gown/apron, gloves, and a mask if aerosolization occurs, and that barrier attire should be removed when leaving the soiled linen area. During observation, the laundry aide stated she used gloves only unless items came in a yellow bag, which she associated with COVID, and said she did not normally wear a gown when sorting clothes or doing laundry. The surveyor observed the laundry aide folding towels and a mechanical lift sling without a barrier between her clothing and the linen, placing clean whites into a clean cart without a barrier between her clothing and the clean clothes, and handling dirty towels, soaker pads, and linen while wearing gloves but without a barrier between her clothing and the soiled linen. The Maintenance Director, who supervised laundry services, stated staff were expected to wear appropriate PPE anytime they worked with dirty linen and that sorting dirty linens required a gown with gloves and a shield if splash was possible.
Incomplete transfer notices and missing bed hold and ombudsman notifications
Penalty
Summary
The facility did not ensure that written transfer or discharge notices were provided to residents or their legal representatives with the required information, and did not ensure the State Ombudsman was notified of transfers for some residents. The report states that 5 of 5 residents, including R5, R7, R11, R13, and R35, did not receive complete written notice of the reason for transfer or discharge, and 3 of 5 residents, including R5, R7, and R11, did not receive a bed hold. The facility policy titled Transfer and Discharge, revised in December 2025, required that the notice include the specific reason and basis for transfer or discharge, the effective date, the specific location, and evidence that the notice was sent to the ombudsman. R13 was cognitively intact with a BIMS score of 13 and had MDS discharge return anticipated dates of 2/25/26 and 4/15/26; the transfer notices reviewed were missing required information, including the date, location, and reason for transfer, and the later notice also lacked R13's name. R11 was cognitively intact with a BIMS score of 15 and had MDS discharge return anticipated dates of 1/4/26, 3/14/26, and 3/28/26; the transfer notice reviewed was missing the date, name, location, and reason, there was no notice for the 3/14/26 transfer, and the 3/28/26 notice was missing the location and reason. R35 was cognitively intact with a BIMS score of 13, but surveyors could not locate a transfer notice or R35's name on the Ombudsman list, and the Interim Nursing Home Administrator stated there was no transfer notice and the Ombudsman was not notified. R5, who had diagnoses including end stage renal disease, Ehlers-Danlos syndrome, asthma, kidney transplant rejection, heart failure, fibromyalgia, dialysis dependence, anxiety, depression, and anemia, was transferred to the hospital and no transfer notice forms or bed hold agreements were found. R7, who had diagnoses including hemiplegia following cerebral infarction, aphasia, end stage renal disease, chronic kidney disease, diabetes mellitus, encephalopathy, depression, dysphagia, anorexia, pulmonary embolism, and anemia, was transferred to the hospital and the 1/12/26 transfer form did not list a reason for transfer; no transfer forms or bed hold agreements were found for the 1/16/26 hospital transfer.
PASARR Level II Screening Not Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed appropriately for 1 of 2 residents reviewed. The resident was admitted with a BIMS score of 14, indicating cognitive intactness, and had diagnoses of schizophrenia and bipolar disorder. The 5-day MDS marked Section A, subsection 1500 as No. The PASARR Level I completed on 3/13/26 indicated the resident had a major mental disorder, had symptoms suggesting a major mental illness, had received psychotropic medication to treat symptoms or behaviors of a major mental disorder, and had a diagnosis or history of intellectual disabilities. It also indicated a hospital discharge exemption with a 30-day maximum and stated that no PASARR Level II was required. During interview, the MDS Nurse stated she relied on what Social Services entered on the Level I and initially said the Level I would have triggered a Level II if needed. Social Services later explained the resident had been expected to return to a group home where he had lived for 15 years, but that facility closed while he was in the nursing home. Social Services confirmed the resident was past the 30 days since admission and stated she would begin checking dates every Monday for a Level II screen based on the 30-day exemption.
Trauma-Informed Care Plan Missing Resident Triggers
Penalty
Summary
The facility did not ensure that trauma informed care was provided in accordance with professional standards of practice for 1 of 2 residents reviewed for PTSD. R11 was admitted with diagnoses including depression, PTSD, adult failure to thrive, personal history of suicidal behavior, and obsessive-compulsive disorder, and had a BIMS score of 15 indicating cognitive intactness. A trauma informed care assessment completed at the facility identified that R11 had been held underwater by friends until he nearly drowned and that, because of this experience, he was afraid of taking a shower. The care plan reviewed for R11 addressed behavior problems related to opioid abuse, alcohol dependence, major depressive disorder, and PTSD related to water, with a goal of no evidence of behavior problems and an intervention for R11 to walk around the facility using a walker to alleviate stress. However, the surveyor was unable to find triggers based on the trauma assessment in the care plan. The Director of Clinical Services stated that R11's care plan did not include the triggers and had been updated, and that the facility was reviewing PTSD care plans to ensure triggers were individualized.
Unsecured storage of controlled medication in medication room refrigerator
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles in the medication storage room. Surveyors observed that the refrigerator in the medication room was unlocked when they entered with an RN, and inside were plastic boxes and zip locks containing residents’ extra unopened labeled medications. A rectangular box holding stock supply liquid Ativan was also observed in the refrigerator, and the RN stated it should be locked. The facility policy stated that controlled substances are to be stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel, and that compartments containing drugs shall be locked when not in use. During follow-up observation and interview with the DCS and ADON, the refrigerator was locked, but the DCS stated that Ativan should be double locked in the medication cart and medication room, with the medication room door counting as one lock. The ADON opened the refrigerator and identified the smaller rectangular box as Ativan. When asked whether a zip tie would serve as a second lock, the DCS stated it would not. The report also noted that the facility did not ensure controlled medication Lorazepam was double locked in a permanently affixed compartment.
Deficient Food Handling and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to prepare, store, and distribute food in a sanitary manner, as evidenced by multiple observations and record reviews. A dietary aide was observed using an alcohol prep pad to sanitize a thermometer probe and immediately inserting it into glasses of milk and juice intended for resident consumption, without allowing the probe to air dry. The dietary aide stated she had not been instructed to wait for the probe to air dry before use, and the facility's policy did not specify this step. The dietary manager confirmed that the expectation was for the probe to air dry before being used in food or beverages. Additionally, the storage of resident food items brought in from outside sources was not in compliance with facility policy. The surveyor found multiple food items in the resident refrigerator that were either not labeled with resident names, not dated, or both. Some items were also kept beyond the facility's stated three-day limit for storage. The dietary manager acknowledged that all items should be labeled with the resident's name and date of entry and disposed of within the required timeframe. Further, dishwashing procedures were not followed to prevent contamination. The dietary aide was observed washing dirty dishes without wearing an apron or gloves, resulting in her shirt becoming visibly wet and soiled with food debris. She then handled and put away clean dishes while her shirt was still dirty and wet, causing direct contact between her contaminated clothing and the clean dishes. Clean dishware, including plate covers, was also put away while still wet, contrary to the facility's policy requiring air drying. The dietary aide indicated she was not informed about the need for an apron or gloves, and the dietary manager acknowledged the risk of contamination from these practices.
Failure to Implement and Maintain Effective Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not follow established protocols for personal protective equipment (PPE), hand hygiene, and the timely implementation of contact precautions. Several residents exhibiting symptoms of gastrointestinal illness, such as nausea, vomiting, and diarrhea, were not promptly placed on appropriate contact precautions. In multiple cases, signage indicating the need for contact precautions was either missing or not posted in a timely manner, despite residents actively displaying symptoms and staff being aware of their conditions. Certified Nursing Assistants (CNAs) were observed not adhering to PPE requirements and proper hand hygiene practices. For example, one CNA wore a surgical mask below her nose during an outbreak of respiratory, COVID-19, and gastrointestinal illnesses, and continued to do so while passing lunch trays and entering resident rooms. Other CNAs entered rooms of residents on contact precautions without donning the required gown and gloves, and in some cases, failed to perform hand hygiene before donning PPE. Additionally, staff were observed handling soiled linens without gloves and without bagging the linens before removing them from resident rooms, contrary to facility policy and standard precautions. Interviews with staff, including the Director of Nursing (DON) and the Infection Control Preventionist (ICP), confirmed that the observed practices did not meet facility expectations or policy requirements. Staff acknowledged the need for proper PPE use, hand hygiene, and the handling of soiled linens as outlined in facility policies. However, the observed lapses in infection control practices, delayed implementation of precautions, and lack of staff awareness regarding procedures contributed to the deficiency in maintaining a safe and sanitary environment to prevent the transmission of communicable diseases and infections.
Failure to Report Allegation of Exploitation
Penalty
Summary
The facility failed to report an allegation of exploitation involving a resident, identified as R131, to the State Survey Agency immediately upon learning of the incident. The incident involved a Certified Nursing Assistant (CNA) taking a picture of the resident's private area with a personal cell phone to show another staff member that the wrong cream was applied. This action was reported by the day shift staff to the Director of Nursing (DON), who observed the CNA delete the picture and completed a disciplinary action. However, the Nursing Home Administrator (NHA) did not report the incident to the State Agency, citing a misinterpretation of the regulation and the absence of ill intent. R131, who was not in the facility at the time of the investigation, was admitted with cerebral palsy and epilepsy and was dependent on staff for emotional, intellectual, physical, and social needs due to impaired cognitive function and thought processes. The facility's policy required immediate reporting of such allegations, but the NHA and DON failed to comply with this requirement. The surveyor's review of the investigation file confirmed the incident but found no documentation of it being reported to the State Agency.
Inaccurate MDS Coding for PASARR Level 2 Completion
Penalty
Summary
A deficiency occurred when the facility failed to accurately code the Minimum Data Set (MDS) for one resident. The resident, who was admitted with diagnoses including depression, anxiety, and PTSD, had a Preadmission Screening and Resident Review (PASARR) level 2 screen completed prior to the MDS assessment. However, the comprehensive MDS assessment incorrectly indicated that no PASARR level 2 had been completed, despite documentation showing otherwise. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS should have reflected the completed PASARR level 2 screen. The error was identified through record review and staff interview, specifically noting the inconsistency between the resident's documented mental health diagnoses and the coding on the MDS assessment.
Failure to Address PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide appropriate interventions in the comprehensive care plan to address the needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident was admitted with diagnoses including anxiety, depression, and PTSD, and was found to be cognitively intact and independent in daily activities. A trauma-informed care assessment identified loud noises as a trigger for the resident's PTSD. However, the care plan did not include specific interventions or mention loud noise triggers, despite this information being documented in the assessment. During interviews, staff members, including CNAs and LPNs, were unaware that any residents had PTSD, indicating a lack of communication and training regarding the resident's diagnosis and care needs. The Director of Nursing acknowledged that the care plan should have been clearer and that staff should have been informed about the resident's triggers and appropriate interventions. The deficiency was identified through record review and staff interviews, which confirmed the absence of necessary care plan details and staff awareness.
Inadequate Supervision and Training in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and proper procedures during mechanical lift transfers, resulting in a fall incident involving a resident. The resident, who was admitted for rehabilitation services following a right below the knee amputation, required assistance with mechanical lift transfers. On the day of the incident, two CNAs attempted to transfer the resident from a wheelchair to a bed but did not place the sling correctly under the resident. As a result, the resident began to slip from the sling, and the CNAs had to assist the resident to the floor to prevent further injury. Although the resident did not report pain or injury, this incident was classified as a witnessed fall. The root cause of the incident was identified as improper placement of the sling by the staff, which was not positioned adequately beneath the resident's buttocks and legs. This deficiency in staff training and supervision placed not only the involved resident but also other residents requiring mechanical lift transfers at risk for similar accidents or injuries. The facility's delay in scheduling comprehensive training for all direct care staff further exacerbated the risk, as the training was planned 25 days after the incident, leaving other residents vulnerable during this period.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Bloomer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - Bloomer | 0.6 mi | ★★★★★ | 1 | 0 |
| Dove Healthcare - Regional Vent Center | 12.1 mi | ★★★★★ | 13 | 0 |
| Wi Veterans Home At Chippewa Falls | 13.4 mi | ★★★★★ | 0 | 0 |
| Chippewa Manor Nursing And Rehabilitation | 13.6 mi | ★★★★★ | 6 | 0 |
| Meadowbrook At Chetek | 16.9 mi | ★★★★★ | 19 | 0 |
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