Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Oconto Falls during CMS and state inspections, most recent first.
Surveyors found that two cognitively intact residents who smoked or vaped were allowed to keep and use their smoking and vaping materials contrary to facility policy and their care plans. One resident with quadriplegia, COPD, diabetes, anxiety, and nicotine dependence kept multiple vaping devices in the room and reported frequent in‑room vaping, despite a care plan and Safe Smoking Evaluation requiring materials to be stored at the nurses’ station and use only in designated areas. Staff, including a CNA, an LPN, and a medication technician, acknowledged awareness of the resident’s in‑room vaping and that the resident turned in only empty devices, while the smoking materials lock box contained none of the resident’s items. Another resident with acute kidney failure, diabetes, and nicotine dependence kept cigarettes and a lighter in the room and on their person, walked past staff with cigarettes, and smoked outside after leaving the building, despite a care plan requiring smoking materials to be turned in between use. Staff interviews confirmed that this resident usually retained smoking materials, that there was no consistent follow‑up to ensure storage in the lock box, and that the lock box did not contain the resident’s materials, in conflict with the facility’s Safe Smoking/Tobacco Use Policy.
A resident with severe cognitive impairment was not protected from abuse by another resident with a history of inappropriate sexual behavior. The incident occurred in the dining room, and despite being reported, the facility failed to assess the vulnerable resident for injury or implement supervision measures. Staff interviews revealed inconsistent documentation and communication regarding the incident and the residents' behaviors.
A resident with severe cognitive impairment and behavioral disturbances frequently wandered into other residents' rooms, causing distress and fear. Despite multiple residents reporting grievances about this behavior, the facility failed to document or resolve these concerns effectively. Staff were aware of the behavior but did not implement effective interventions, and the facility's grievance policy was not followed, leaving residents' concerns unaddressed.
A facility failed to report an alleged sexual abuse incident involving a resident with severe cognitive impairment. The incident, witnessed by another resident, was not reported to the State Agency as required by the facility's policy. The leadership team decided against reporting, citing a lack of intent from the alleged perpetrator.
A facility failed to report and thoroughly investigate an alleged sexual abuse incident involving two residents. Despite a guardian's report of one resident fondling another, the facility did not notify authorities or conduct a timely investigation. Discrepancies in staff statements and delayed resident interviews further highlighted the facility's inadequate response.
A resident with severe dementia and behavioral disturbances was inadequately supervised and lacked an updated care plan, leading to safety concerns. The resident frequently wandered and exhibited aggressive behaviors, such as yelling and biting, which were not effectively managed by the facility. Despite receiving medications, there were no adjustments made, and staff interventions were often ineffective, resulting in a deficiency in providing a safe environment.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their needs and concerns. A resident with severe cognitive impairment frequently called out, but their care plan lacked interventions to manage this behavior. Two other residents expressed concerns about the noise, but their care plans did not include coping strategies. Additionally, a resident's care plan was not updated to reflect changes in supervision needs, causing confusion during an altercation.
Two residents expressed concerns about a neighboring resident frequently calling out, but the facility failed to document or resolve their grievances. Despite attempts to manage the behavior of the resident causing the disturbance, the affected residents were not provided with effective solutions, and their complaints were not escalated or formally recorded, violating the facility's grievance policy.
A resident with hemiplegia and hemiparesis fell out of a Hoyer lift during a transfer conducted by a CNA alone, contrary to the care plan requiring two staff. The resident experienced significant pain and a delayed diagnosis of a left hip fracture due to inadequate assessment and investigation by the facility staff.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours per day, 7 days per week. There was no RN on duty from 6:05 PM on 5/17/24 until 12:00 PM on 5/19/24. The DON confirmed the scheduled RN did not come in, and although the DON worked on 5/19/24, they did not punch in and out on the time clock.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance logs and staff not adhering to proper infection control practices. A Laundry Aide entered a resident's isolation room without PPE, and an LPN did not perform hand hygiene after glove removal. Another LPN used scissors on a resident's wound without disinfecting them between uses, violating equipment protocol.
The facility failed to ensure complete informed consent for medications for four residents, including psychotropic drugs. Consent forms lacked necessary information such as dosage ranges and alternative treatments, and were not properly initialed and dated. The DON confirmed these deficiencies, highlighting a lapse in ensuring residents or their representatives were fully informed about medication risks and benefits.
The facility did not ensure that the PCV20 vaccine was reviewed, offered, and administered to four residents with significant medical histories, despite CDC recommendations. The Infection Preventionist acknowledged the oversight and had not audited or offered the vaccine to existing residents.
The facility failed to maintain mechanical lift equipment safely, affecting 17 residents. Observations showed wear and tear, with issues like rust, hair in wheels, and broken emergency pulls. Residents and CNAs reported feeling unsafe, with lifts described as old and slow. Maintenance inspections did not note concerns, and a list of repairs was not provided. The facility was ordering parts to address issues.
A resident with a pressure injury on the left heel was not provided with the necessary care to prevent further breakdown, as staff failed to ensure the resident wore a heel boot as prescribed. The care plan and Kardex were not updated to reflect the intervention, and CNA staff were unaware of the requirement. The resident had moderately impaired cognition and was admitted with multiple diagnoses, including multiple sclerosis and osteoarthritis.
Two residents with indwelling catheters were observed with uncovered drainage bags in contact with the floor, contrary to the facility's policy and infection control practices. The facility's catheter policy requires bags to be covered, but does not address proper positioning. Staff confirmed the bags should not be on the floor, highlighting a lapse in adherence to infection prevention protocols.
The facility failed to provide adequate respiratory care and monitoring for three residents. A resident used oxygen therapy without a physician's order, and their care plan did not address this therapy. Two residents on droplet and contact precautions lacked consistent monitoring for respiratory symptoms. The facility's policies on oxygen use and isolation precautions were not properly followed, leading to these deficiencies.
A facility failed to maintain a signed and dated contract with the correct dialysis center for a resident requiring dialysis services. The resident, with end-stage renal disease, received treatment at an outside center three times weekly. The contract had incorrect names and lacked a date and signature page. The DON explained a merger caused the discrepancy, but the facility could not provide the necessary documentation.
A resident with diabetes did not receive timely administration of Fiasp insulin due to a delay of over an hour between the blood sugar check and insulin administration. The LPN failed to educate the resident on the importance of accurate dosing based on current blood sugar levels, leading to a deficiency in pharmaceutical services.
A resident prescribed mirtazapine for depression was not monitored for adverse reactions or effectiveness, as their care plan lacked necessary interventions. The resident, with intact cognition and responsible for their healthcare decisions, was admitted with multiple injuries. The deficiency was confirmed by the DON.
A long-term care facility experienced a 20% medication error rate during observations, affecting three residents. Errors included incorrect doses of Miralax, vitamin B-complex, vitamin B12, and a multivitamin. An LPN admitted to the mistakes, and the Director of Nursing confirmed these as medication errors.
Failure to Enforce Smoking and Vaping Safety Policies for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision related to smoking and vaping for two cognitively intact residents. Facility policy, revised 1/2026, states that smoking is not permitted in the facility or where oxygen is in use, that residents who smoke or use e‑cigarettes must be evaluated for safe or unsafe use, and that staff are to maintain all smoking materials, including e‑cigarettes, as appropriate for the resident. The policy further requires that smoking, smokeless tobacco use, and e‑cigarette use occur only in designated locations that are environmentally separate from resident care areas, and that staff maintain smoking materials in a secure area such as the nurses’ station, distributing them only at smoking times or via a locked container for residents deemed safe. One resident (R1), with diagnoses including quadriplegia, COPD, diabetes, anxiety, and nicotine dependence, had a BIMS score of 15/15 and was responsible for their own medical decisions. R1’s care plan documented that the resident chose to vape, was to vape only in designated areas, and was to turn in smoking materials when not smoking, with encouragement to leave all smoking items at the nurses’ station. The care plan also documented that R1 was non‑compliant with the smoking policy and had been observed vaping in the room, and that a risk versus benefits form had been completed because R1 continued to vape in the room. A Safe Smoking Evaluation dated 3/4/26 indicated R1 had been informed that all smoking materials must be secured at the nurses’ station or other designated area when not in use and that R1 must request smoking materials from staff. Despite this, the surveyor observed two vaping devices in R1’s room, including one plugged into a computer, and R1 reported vaping in the room at night and in the morning, approximately 10 to 20 times or more per hour, keeping the devices in the room and using them inside the facility. Multiple staff confirmed awareness of R1’s in‑room vaping and the presence of vaping devices. A CNA stated staff and management were aware that R1 had and used the devices in the room. An LPN reported knowing that R1 vaped in the room and that the DON had previously been involved in a contract for R1 to store vaping materials at the nurses’ station, but that R1 had been openly vaping for a long time and had turned in only empty devices while keeping usable ones. A medication technician also knew R1 had vaping devices in the room and stated R1 turned in used, non‑working devices while keeping functional ones. When the surveyor and the medication technician checked the smoking materials lock box, there were no materials for R1, contrary to the care plan and policy requirements. A second resident (R2), with diagnoses including acute kidney failure, diabetes, and nicotine dependence on cigarettes, also had a BIMS score of 15/15 and was responsible for their own medical decisions. R2’s care plan stated that the resident chose to smoke cigarettes, would smoke only in designated areas, and would turn smoking materials into nursing staff for safekeeping between smoking, with re‑evaluation if safety became a concern. A Safe Smoking Evaluation indicated R2 had been informed of the evaluation results. However, the surveyor observed R2 in the room holding a pack of cigarettes, then placing the cigarettes in a pocket, passing the nurses’ station with staff present, exiting the building, and lighting a cigarette. R2 initially denied keeping smoking materials in the room but then admitted doing so and stated that once cigarettes were picked up in the morning, they were kept by the resident. Staff interviews confirmed that R2 routinely retained smoking materials instead of turning them in as required. A CNA stated R2 usually kept cigarettes and a lighter for convenience and did not return them to the nurses’ station. The LPN acknowledged knowing that R2 kept smoking materials and stated that, although materials were supposed to be stored in a lock box behind the nurses’ station, there was no follow‑up or consistency, so R2 and other residents kept their materials. The medication technician reported being aware that R2 kept cigarettes and lighters and believed R2 was not a supervised smoker and could keep these items, also noting that R2 often obtained cigarettes from other residents. When the surveyor and medication technician checked the smoking materials lock box, there were no materials for R2. The DON stated that staff and residents should follow the smoking policy and that staff were supposed to keep R1 and R2’s smoking materials, which should not be kept on their person or in their rooms, and reported not being aware that R1 kept vaping materials in the room or vaped in the room.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident with severe cognitive impairment who was vulnerable due to wandering unsupervised. This deficiency involved a resident with a history of sexually inappropriate behavior who allegedly groped the vulnerable resident in the dining room. Despite the incident being reported to the Nursing Home Administrator, the vulnerable resident was not assessed for injury, and no interventions were put in place to supervise the residents involved. The facility's staff did not adequately document or investigate the incident. The medical records of the involved residents did not reflect the alleged sexual assault or any subsequent assessments. Interviews with staff revealed a lack of consistent communication and documentation regarding the incident and the residents' behaviors. The staff's accounts varied, with some indicating that the inappropriate behavior was ongoing and not effectively managed. The facility's policies on abuse prevention and resident protection were not followed, as evidenced by the lack of immediate investigation and protective measures. The failure to supervise the resident with a history of inappropriate sexual behavior and the vulnerable resident who wandered unsupervised created a situation of immediate jeopardy, which was not addressed until much later. The facility's inaction and inadequate response to the incident contributed to the deficiency.
Removal Plan
- Initiated one-to-one supervision for R9 who will be at least arms-length from and not seated near female residents.
- Updated R9's behavior care plan and implemented interventions in accordance with R9's behavior patterns.
- Consulted with R9's providers for suggestions and interventions.
- Educated staff on abuse, behavior documentation, and updated care plan interventions.
Failure to Address Resident Grievances Regarding Wandering Behavior
Penalty
Summary
The facility failed to acknowledge and resolve grievances related to a resident, R2, who exhibited wandering behavior and entered other residents' rooms uninvited. R2, diagnosed with severe cognitive impairment and behavioral disturbances, was known to wander into rooms, rummage through belongings, and exhibit aggressive behavior. Despite multiple residents, including R3, R4, R6, R7, and R8, expressing concerns about R2's behavior, the facility did not document these grievances or implement effective interventions to prevent R2 from entering their rooms. R3 filed a formal grievance after R2 entered R3's room and rummaged through belongings, but the facility did not follow up or resolve the issue. R4, R6, R7, and R8 also reported R2's unwelcome presence in their rooms, with R4 describing a specific incident where R2 blocked the exit and acted aggressively. Despite these reports, the facility did not document these concerns as grievances or take action to prevent further incidents. Staff interviews revealed that R2's behavior was known, but interventions such as redirection were ineffective, and no new strategies were implemented. The facility's grievance policy requires that all concerns be documented and addressed promptly, but this was not adhered to in the case of R2's behavior. The Nursing Home Administrator and Director of Nursing were unaware of the extent of the grievances and did not take appropriate action to address the residents' concerns. The lack of documentation and follow-up on these grievances highlights a failure in the facility's grievance process, leaving residents feeling unsafe and their concerns unaddressed.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, R2, to the State Agency (SA) as required by their Abuse Prevention Program policy. The incident occurred when R9 allegedly groped R2's breast in the cafeteria, witnessed by R10, who reported the incident to R2's guardian and the Nursing Home Administrator (NHA). Despite the report, the facility's leadership, including the Director of Nursing (DON), NHA, Chief Nursing Officer (CNO), and Regional Director of Operations (RDO), decided not to report the incident to the SA, citing a lack of intent from R9 as the reason. R2, who has severe cognitive impairment due to non-Alzheimer's dementia, was unable to advocate for themselves, and the incident was brought to light by R10 and R2's guardian. R10, who is cognitively intact, witnessed the incident and attempted to intervene before staff moved R9 away from R2. The facility's policy mandates immediate reporting of abuse allegations to regulatory agencies, but this protocol was not followed, as the leadership team concluded that the incident was not reportable. This decision was made despite the clear policy requirements and the serious nature of the allegation.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the State Agency. On 10/23/24, a guardian reported that a resident fondled another resident's breast in the dining room. Despite the report, the facility did not conduct a thorough investigation or notify the appropriate authorities as required by their Abuse Prevention Program policy. The policy mandates that all incidents, whether or not abuse is confirmed, should be documented and investigated, and that local law enforcement should be contacted in cases of intentional sexual touching. The incident involved a resident with severe cognitive impairment and a guardian as the decision-maker, and another resident who was not cognitively impaired. The guardian and another resident witnessed the incident and reported it to the facility staff, but the Nursing Home Administrator (NHA) did not initiate an investigation until prompted by the guardian the following day. The NHA reviewed video footage but denied the guardian's requests to view it, and the facility did not report the incident to the police. The guardian expressed dissatisfaction with the facility's handling of the incident and the care provided to the resident. Discrepancies were noted in the statements from staff members regarding the incident, and the facility's documentation was inconsistent. The NHA's notes indicated that the incident did not involve abuse, and the guardian was reportedly fine with this determination, although this was contradicted by the guardian's statements. Additionally, the facility failed to conduct a skin assessment for the resident involved, and resident interviews to ensure safety and freedom from abuse were not completed until several weeks after the incident.
Inadequate Supervision and Care Planning for Resident with Dementia
Penalty
Summary
The facility failed to ensure appropriate supervision and care planning for a resident with severe dementia and behavioral disturbances, leading to safety concerns for the resident and others. The resident, identified as R2, exhibited wandering behavior and was physically and verbally aggressive. Despite these behaviors, the facility did not revise R2's care plan to include effective behavioral and monitoring interventions. The care plan initially included goals to prevent R2 from leaving the facility unattended and to prevent harm to R2 or others, but it lacked updates to address the resident's increasing behavioral issues. Observations and interviews revealed that R2 frequently wandered into other residents' rooms and exhibited aggressive behaviors such as yelling, hitting, and biting. Staff members, including CNAs and nurses, reported that R2's interventions, such as redirecting and providing a baby doll, were often ineffective. The facility's Dementia Care policy required individualized care plans and monitoring by a behavior committee, but there was no evidence that R2's care plan was updated or that the physician was notified of the resident's frequent and severe behaviors. The surveyor's review of R2's medical and treatment records indicated that the resident received medications for anxiety and dementia, but there were no adjustments made despite the increased frequency of behaviors. Interviews with staff confirmed that R2's behaviors were not effectively managed, and the resident continued to pose a risk to themselves and others. The facility's failure to implement and document appropriate interventions and supervision for R2 resulted in a deficiency in providing a safe environment for all residents.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans were updated for four residents, leading to deficiencies in addressing their needs and concerns. Resident 3, who had severe cognitive impairment and frequently called out, did not have an updated care plan to reflect this behavior or include interventions to manage it. Despite multiple progress notes indicating the resident's vocalizations and the administration of medications like lorazepam and tramadol, the care plan lacked specific strategies to address the calling out behavior. Interviews with staff revealed that interventions such as changing the resident's position or environment were used, but these were not documented in the care plan. Residents 4 and 5, who were cognitively intact, expressed concerns about the frequent calling out by Resident 3, which affected their well-being. However, their care plans did not include interventions to assist them in coping with the disturbances. Resident 5, who suffered from claustrophobia, was not offered alternatives like a sound machine, and Resident 4 reported feeling more short-tempered due to the noise. The social worker acknowledged the importance of having care plan interventions for these residents but noted that they were not in place. Resident 2's care plan was not updated to reflect changes in supervision needs, leading to confusion during an altercation with another resident. Initially on 1:1 supervision, the care plan was not revised to indicate the current level of supervision, resulting in uncertainty among staff about the required checks. Interviews with nursing staff revealed a lack of clarity regarding the supervision level, which contributed to the incident. The Director of Nursing confirmed that care plans should be updated with any changes in a resident's plan of care.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for two residents, R4 and R5, who expressed concerns about another resident, R3, frequently calling out. Despite the facility's policy requiring grievances to be documented and addressed, no grievance forms were completed for R4 and R5. Both residents had intact cognition and reported their concerns to multiple staff members, but their grievances were not formally recorded or resolved. R3, who had severely impaired cognition due to a stroke, frequently called out, causing distress to neighboring residents. Medical interventions, including medication adjustments, were attempted to address R3's behavior, but these efforts were not communicated effectively to R4 and R5. R5 reported difficulty sleeping due to R3's behavior and was not offered any solutions other than closing the door, which was not feasible due to claustrophobia. R4 also expressed frustration with the ongoing disturbances and felt that nothing had been done to address the issue. Staff members, including a CNA and an LPN, acknowledged the concerns raised by R4 and R5 but did not escalate the grievances to the Director of Nursing or complete the necessary documentation. The Social Worker was aware of the concerns and sought guidance from the Ombudsman but did not fill out grievance forms for R4 and R5. This lack of documentation and follow-through resulted in the facility's failure to honor the residents' right to voice grievances and ensure prompt resolution, as required by their policy.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility did not ensure a safe environment free from accident hazards for a resident who fell out of a Hoyer lift during a transfer conducted by a CNA alone. The resident, who had a history of hemiplegia and hemiparesis following a stroke, reported the fall to staff the following day and was later diagnosed with a left hip fracture. The resident's care plan indicated the need for a full mechanical lift with the assistance of two staff for all transfers, which was not followed during the incident. The facility's investigation revealed that the CNA used a sit-to-stand lift and a Hoyer lift alone to transfer the resident, contrary to the care plan requirements. The resident experienced significant pain following the fall, which was not adequately assessed by the staff, leading to a delay in diagnosis and treatment. The resident's medical record showed multiple requests for pain relief, and the resident expressed a desire to go to the emergency room, which was initially dismissed by the staff. Interviews with various staff members and a review of the facility's camera footage confirmed that the CNA did not follow proper transfer protocols and that the incident was not promptly reported or investigated. The Director of Nursing and other staff members failed to conduct a thorough assessment and investigation immediately after the resident reported the fall, resulting in a delay in addressing the resident's pain and injury. The facility's policies on change of condition and abuse prevention were not adequately followed, contributing to the deficiency in providing a safe environment for the resident.
Failure to Ensure RN Coverage
Penalty
Summary
The facility did not ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days per week, as required. This deficiency was identified through staff interviews and record reviews. Specifically, there was no RN on duty from 6:05 PM on 5/17/24 until 12:00 PM on 5/19/24. The facility's assessment, revised on 5/14/24, indicated that an RN would be on duty as required, but this was not adhered to. The facility did not have a waiver related to staffing or having an RN on duty. The Director of Nursing (DON) confirmed that the RN scheduled for the weekend did not come in, and although the DON worked on 5/19/24 from approximately 12:00 PM to 8:00 PM, they did not punch in and out on the time clock.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews conducted by surveyors. The facility did not maintain an infection tracking and surveillance log, which is crucial for detecting disease transmission patterns. The Infection Preventionist admitted to being behind on documentation, resulting in incomplete and inaccurate records for April 2024. This oversight had the potential to affect all 50 residents in the facility, as timely and accurate documentation is essential for monitoring and controlling infections. In addition to documentation issues, staff members were observed not adhering to proper infection control practices. A Laundry Aide entered a resident's room, which was under contact and droplet precautions, without donning the required personal protective equipment (PPE) or performing hand hygiene. This action was contrary to the facility's policy and the expectations of the Director of Nursing, who confirmed that all staff, including laundry personnel, should follow PPE guidelines when entering isolation rooms. Further deficiencies were noted in the provision of care by nursing staff. An LPN failed to perform hand hygiene after removing gloves during a blood sugar check for a resident, which is a critical step in preventing cross-contamination. Another LPN used scissors to cut a soiled dressing and then a clean dressing for a resident's wound without disinfecting the scissors in between, violating the facility's equipment protocol. These actions demonstrate a lack of adherence to established infection control procedures, potentially compromising resident safety.
Incomplete Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents or their legal representatives were fully informed and understood the risks and benefits of prescribed medications, as required by their own policy and state regulations. This deficiency was identified for four residents who were prescribed various medications, including psychotropic drugs. The informed consent forms for these medications were incomplete, lacking necessary information such as anticipated dosage ranges, alternative treatments, and probable consequences of not receiving the medication. Additionally, the forms were not properly initialed and dated by the residents or their representatives. One resident, with intact cognition, was prescribed mirtazapine but the consent form was missing critical information and was not fully completed. Another resident, with severely impaired cognition, had a Power of Attorney for Healthcare (POAHC) responsible for their decisions. The POAHC signed consent forms for multiple medications, but these forms were incomplete and not properly initialed or dated. A third resident, also with severely impaired cognition, had a consent form for quetiapine that was not fully completed, and the resident did not initial or date the form as required. The fourth resident, with intact cognition, was prescribed several medications with black box warnings. The consent forms for these medications were signed but not properly initialed and dated. The Director of Nursing confirmed the deficiencies in the consent forms for all four residents, acknowledging the importance of complete and accurate documentation for informed consent.
Failure to Administer PCV20 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that vaccinations were reviewed, offered, and administered to four residents, specifically the PCV20 vaccine, as per the CDC recommendations. The residents involved were R17, R18, R20, and R23, each with significant medical histories including chronic kidney disease, multiple sclerosis, cancer, and pneumonia, respectively. Despite having received previous pneumococcal vaccinations (PPSV23 and PCV13), there was no indication in their medical records that they were offered or administered the PCV20 vaccine. The deficiency was identified during a survey where the Infection Preventionist (IP)-C acknowledged that residents should be offered the PCV20 vaccine upon admission. However, IP-C admitted to not having audited or offered the PCV20 vaccine to existing residents. This oversight was noted during an interview with the surveyor, where IP-C mentioned working with regional support to develop a process for monitoring PCV20 vaccinations.
Deficiency in Mechanical Lift Maintenance
Penalty
Summary
The facility failed to maintain mechanical lift equipment in a safe operating condition, affecting 17 residents who relied on these lifts for transfers. Observations and interviews revealed that the lifts showed signs of wear and tear, with issues such as rust-like substances on the legs and wheels, hair caught in the wheels, and duct tape on handles. Additionally, the emergency pull on one of the lifts was broken, and the lifts were described as old, slow, and unsafe by both residents and staff. Two residents, both with intact cognition, expressed concerns about the lifts. One resident reported feeling unsafe and experiencing pain due to the slow operation of the lifts, while another resident mentioned the lifts were old and did not work well. Certified Nursing Assistants (CNAs) also expressed concerns, noting that the lifts were rickety, wobbly, and had issues with the legs spreading during transfers. The emergency pull on a stand lift was demonstrated to be non-functional, causing discomfort to residents. The Maintenance Supervisor stated that lifts were inspected monthly, but acknowledged issues with battery life and the emergency pull on one lift. Despite monthly inspections, the inspection sheets did not note any concerns, and a list of repair requests was not provided. The Director of Nursing confirmed swapping an older lift with a newer one for a resident's transfer after concerns were raised, but was unaware of other residents' concerns. The facility was in the process of ordering parts to address the shifting legs of the lifts.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of or promote healing for a resident with a pressure injury. The resident, who had a pressure injury on the left heel, was observed on multiple occasions not wearing the prescribed heel boot while out of bed. The care plan for the resident was not updated to reflect the intervention of wearing a heel boot at all times except during walking and transfers. The CNA staff was unaware of the requirement for the resident to wear the heel boot during the day, as the intervention was not documented in the resident's Kardex or care plan. The resident, who had moderately impaired cognition, was admitted with diagnoses including multiple sclerosis, osteoarthritis, and a history of falling. Despite a wound note indicating a change in treatment to wearing a heel boot instead of a slipper, the staff failed to implement this intervention. The CNA followed the outdated Kardex and care plan, which did not include the updated order for the heel boot. The Director of Nursing confirmed that the care plan should have been updated and that staff should document if the resident refused to wear the heel boot.
Inadequate Catheter Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling catheters. The surveyor observed that the catheter drainage bags of these residents were uncovered and in contact with the floor, which is against the facility's policy and standard infection control practices. The facility's catheter policy mandates that catheter drainage bags should be covered at all times to maintain dignity and privacy, but it does not address the positioning or placement of tubing or drainage bags. The Relias training provided to nursing staff emphasizes the importance of keeping drainage bags off the floor to prevent contamination and infection. Resident 20, who has chronic kidney disease and moderately impaired cognition, was observed with an uncovered catheter drainage bag visible from the hallway and in contact with the floor. Similarly, Resident 18, who has multiple sclerosis and a history of urinary tract infection and inflammatory reaction due to a urinary catheter, was also observed with an uncovered catheter drainage bag in contact with the floor. Both the Certified Nursing Assistant and the Director of Nursing confirmed that the catheter bags should not be on the floor due to infection control issues, and that education on this matter is provided during various training sessions.
Deficiencies in Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents with respiratory needs. Resident 7 was observed using oxygen therapy without a physician's order, and their care plan did not address the use of oxygen therapy. Despite having standing orders for oxygen use, the facility did not activate these orders in Resident 7's medical record, nor did they initiate a care plan for the oxygen therapy. This oversight was confirmed by the Director of Nursing, who acknowledged that the standing orders should have been activated and a care plan should have been in place. Residents 12 and 2 were placed on droplet and contact precautions due to exposure to pneumonia. However, their medical records lacked consistent monitoring or assessments for respiratory symptoms. Resident 12's record showed only one pulse and temperature reading on two separate days, and Resident 2's record contained minimal documentation regarding respiratory status and the effectiveness of treatment. The Infection Preventionist confirmed that vital signs should be conducted every shift, although this requirement was not included in the facility's isolation precaution policy. The facility's policies on Liquid Oxygen Use and Isolation Precautions were not adequately followed, leading to deficiencies in the care provided to these residents. The Liquid Oxygen Use policy required physician orders for oxygen therapy and regular monitoring of oxygen saturation levels, which were not documented for Resident 7. Additionally, the Isolation Precautions policy lacked specific guidelines for symptom monitoring, contributing to the inadequate monitoring of Residents 12 and 2 during their precautionary period.
Incomplete Dialysis Contract for Resident
Penalty
Summary
The facility failed to ensure they had a signed and dated contract with the correct name of the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including end-stage renal disease and acute renal failure, received hemodialysis at an outside dialysis center three times a week. Despite the facility's policy to ensure proper care and services for hemodialysis, the contract with the dialysis center was found to be inaccurate and incomplete. During the survey, it was discovered that the contract had the name of the original skilled nursing facility and dialysis center blacked out, with new names typed over them. The dialysis center named in the contract did not match the one in the resident's medical record. Additionally, the contract lacked a date and a signature page. The Director of Nursing explained that the current dialysis center and the one named in the contract had merged, which led to the discrepancy. However, the facility was unable to provide a signature page or documentation of the contract date.
Deficiency in Timely Insulin Administration
Penalty
Summary
The facility failed to ensure the timely administration of insulin for a resident with diabetes mellitus, leading to a deficiency in pharmaceutical services. The resident, who had intact cognition and was responsible for their healthcare decisions, was prescribed Fiasp, a short-acting insulin, with dosing based on blood sugar levels. On the morning in question, the resident's blood sugar was checked at 7:45 AM, showing a level of 199 mg/dl. However, the insulin was not administered until 8:57 AM, approximately 1 hour and 15 minutes later, which is beyond the recommended 30-minute window for administering short-acting insulin based on a sliding scale. The LPN involved did not provide the necessary education to the resident about the importance of obtaining a current blood sugar result for accurate dosing. Despite the resident declining a recheck of their blood sugar, the LPN proceeded to administer 28 units of Fiasp without ensuring the dose was accurate based on a current blood sugar reading. This oversight was confirmed during an interview with the LPN, who acknowledged the need for rechecking the blood sugar and educating the resident. The physician also confirmed that short-acting insulin should be administered within 30 minutes of a blood sugar check, highlighting the deficiency in the facility's pharmaceutical services.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to ensure proper monitoring for adverse reactions or the effectiveness of a psychotropic medication for one resident. The resident, who was admitted with multiple fractures and internal injuries following a motor vehicle accident, had a BIMS score indicating intact cognition and was responsible for their healthcare decisions. The resident was prescribed mirtazapine, an antidepressant, but their care plan lacked interventions for staff to monitor for adverse reactions or the medication's effectiveness. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the omission in the resident's care plan.
Medication Error Rate Exceeds 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate during medication administration observations. This affected three residents, with errors occurring in the administration of Miralax, vitamin B-complex with folic acid, vitamin B12, and a multivitamin. One resident received only one-third of the prescribed dose of Miralax, while another was given incorrect doses and types of vitamin supplements. Additionally, a surveyor intervened to prevent the administration of an incorrect insulin dose. The errors were primarily attributed to the actions of an LPN who prepared and administered medications incorrectly. The LPN admitted to the mistakes during interviews with the surveyor, acknowledging the incorrect administration of medications and the preparation of an incorrect insulin dose. The Director of Nursing confirmed these observations as medication errors, highlighting a significant lapse in the facility's adherence to its medication administration policy.
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 69 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Oconto Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Suring Health And Rehab Center | 13.6 mi | ★★★★★ | 6 | 1 |
| Oconto Health And Rehab Center | 13.8 mi | ★★★★★ | 22 | 0 |
| Rennes Health And Rehab Center-west | 22.8 mi | ★★★★★ | 3 | 0 |
| Birch Hill Health Services | 22.9 mi | ★★★★★ | 11 | 0 |
| Evergreen Health Services | 23.3 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Meadowbrook At Oconto Falls.
100% money-back within 48 hours.
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.