Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook At Chetek during CMS and state inspections, most recent first.
The facility failed to prevent multiple significant medication errors when staff did not consistently verify medications against orders, left a med cart unattended, and did not remove discontinued drugs from circulation. A resident with orthostatic hypotension was given another resident’s Oxycontin ER and Amlodipine and required Narcan and hospitalization. Another resident with rib fractures received a discontinued opioid instead of the current pain medication. A hospice resident prescribed Lorazepam oral concentrate was repeatedly given tablet form and later received a dose after the drug was discontinued. Additional errors included a wrong Tacrolimus dose due to transcription error, a resident receiving another resident’s Atorvastatin, and a resident ingesting another resident’s gabapentin, clonidine, and Vitamin D after bedside medication cups were mixed up for two residents with the same initials.
A resident with orthostatic hypotension and a neurocognitive disorder received another resident’s medications, including Oxycontin ER and Amlodipine, from a licensed nurse, leading to administration of Narcan and hospital evaluation where the resident was found markedly orthostatic and required IV fluids and transfer to another hospital. Despite the facility’s abuse prevention policy defining possible neglect as failure to provide necessary goods or services to avoid harm, the DON reported that the incident was not reported to the state agency and the required 5-day investigation was not submitted on time, citing that it was the nurse’s first medication error and that there were no noted signs or symptom effects.
The facility failed to thoroughly investigate and promptly correct an initial opioid medication error, allowing additional serious medication errors to occur. A resident with rib fractures received a discontinued opioid that had not been removed from circulation. Subsequently, another cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER and Amlodipine, and required Narcan, ED care, and hospital transfer. A cognitively intact hospice resident with COPD, chronic pancreatitis, and anxiety, ordered Lorazepam oral concentrate, instead received the wrong dosage form (tablet) on multiple occasions and later received the medication again after it had been discontinued, as it was not removed from circulation. These errors occurred despite existing policy requiring verification of medication labels against orders and after management became aware of the first error but before all licensed nurses were educated.
Two residents were affected when the facility failed to follow its own policy for controlled substance destruction and discontinuation. For one resident, a discontinued Pregabalin (Lyrica) 50 mg order was not destroyed promptly and was documented as destroyed by only one nurse instead of two licensed staff. For another resident, Lorazepam ordered as an oral concentrate for terminal anxiety was logged as 0.5 mg tablets, and the controlled substance log showed doses being administered after the medication had been discontinued. The DON and ADON acknowledged awareness of these medication errors, while an RN described a destruction process involving a drug buster and two nurse signatures that was not followed in these instances.
Two residents did not receive medications in accordance with physician orders and labeling requirements. One hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder was ordered Lorazepam oral concentrate for terminal anxiety but was repeatedly given tablet doses instead, and the drug continued to be administered after it was discontinued. In a separate case, an RN was found using an unlabeled morphine oral solution bottle marked only with a handwritten number, later identified as belonging to a resident, and confirmed that this medication had been administered multiple times without proper labeling or resident identification.
The facility did not accurately report direct care staffing data to CMS via the PBJ system, resulting in underreported weekend staffing levels. Although management and HR staff stated that weekend staffing was consistent with weekdays, a review revealed that hours worked by staff who left employment before data was pulled were omitted from PBJ submissions. This led to the facility being flagged for low weekend staffing, potentially affecting all residents.
A resident with upper limb monoplegia and COPD, requiring assistance with mobility, was found unable to reach their call light, which was wrapped around a bedside rail. The resident reported that staff frequently left the call light out of reach after transfers, despite care plan instructions and facility policy requiring accessibility to minimize fall risk. The DON confirmed staff were aware of the resident's limitations and the need for the call light to be within reach.
A resident with multiple medical conditions and existing pressure injuries did not receive wound care as ordered by the physician. During observed care, an RN failed to perform hand hygiene, did not follow the prescribed wound care steps, and omitted the application of required treatments, resulting in a deficiency in both infection control and adherence to professional standards.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and high fall risk was left unsupervised in the bathroom, resulting in a fall, while another resident who vapes was not properly assessed or care planned for independent smoking, despite facility policy requiring such evaluation.
A resident requiring dialysis did not receive consistent pre- and post-dialysis assessments as required by facility policy and the care plan. Staff failed to document vital signs, weight, or inspection of the dialysis access site before or after dialysis treatments, and the DON confirmed that there was no established process for these assessments. The resident reported that vital signs were only sometimes checked after dialysis, and records showed only weekly documentation unrelated to dialysis sessions.
Staff failed to follow infection control protocols, including proper hand hygiene during wound and personal care, use of PPE for a resident with open wounds, and correct handling of a urinary catheter bag, which was repeatedly observed on the floor. These lapses involved multiple residents with complex medical needs and were not in accordance with facility policies.
The facility failed to follow its food storage and labeling policies, leading to multiple unlabeled and potentially expired food items in the walk-in refrigerator and resident kitchenette. The Dietary Manager and staff admitted to not labeling items with open dates, and expired items were found. The Nursing Home Administrator was unaware of any foodborne illnesses but acknowledged the deficiency after being informed by the Dietary Manager.
A facility failed to return a deceased resident's trust funds to the POA or family within 30 days, as required by policy. The resident's account showed a positive balance, but no conveyance was documented. A family member reported the facility refused to refund the balance, citing an outstanding debt. The NHA was unsure about the balance, and the Accounts Receivable Specialist claimed all accounts are usually settled within 30 days, highlighting a lapse in policy adherence.
Two residents experienced falls that were not immediately reported to the physician, violating the facility's policy. One resident with Alzheimer's disease fell and was not reported until a day later, while another resident with dementia had two unwitnessed falls, with no documentation of physician notification. The DON was unaware of the incidents until observing injuries.
Two residents in an LTC facility did not receive proper assessments following falls, as required by the facility's fall management policy. One resident, with severe cognitive impairment, was not thoroughly assessed after a fall, and the incident was not reported to hospice or family until the next day. Another resident, with dementia, experienced falls without documented assessments, and the DON was unaware of the incidents until observing facial bruising. These deficiencies highlight a failure in maintaining residents' well-being and communication protocols.
The facility failed to implement new fall interventions for three residents at risk for falls. One resident fell and had a planned intervention not added to their care plan. Another resident experienced two falls with no new interventions implemented. A third resident's care plan was not updated after a fall. The DON acknowledged the oversight.
The facility failed to ensure proper hand hygiene and use of hair nets in food service. A CNA entered the kitchen without a hair net, and a Dietary Cook handled food without changing gloves or using hand hygiene after touching unclean items. The Dietary Manager confirmed these practices were against facility policy.
A facility failed to follow physician orders to schedule a follow-up oncology appointment for a resident with a potentially metastatic lesion. The admission checklist process was not effectively executed, and the necessary information was not communicated to the Social Services Assistant responsible for scheduling. Staff interviews revealed confusion and a lack of timely action, resulting in the resident not receiving the required follow-up care.
The facility failed to evaluate hazards related to the use of an oscillating percussion vest for a resident with quadriplegia and high aspiration risk. The resident was observed alone during vest treatments, and staff did not consistently follow physician orders for post-treatment checks. The care plan lacked details on supervision during vest use, and no assessment was conducted to ensure the resident's safety while unsupervised.
A resident with epilepsy, cerebral palsy, and functional intestinal disorder received medication via G-tube without proper verification of tube placement. The LPN used an outdated method of injecting air and listening for noise, which is no longer the standard of practice. The facility's policy still included this outdated practice, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program. Staff did not perform proper hand hygiene during medication administration for a resident with severe cognitive impairment, and droplet precautions were removed prematurely for a COVID-19 positive resident due to a miscalculation of isolation days.
Multiple Significant Medication Errors and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite a policy requiring accurate, safe, and timely medication administration. The policy directs staff to verify medication labels against the medication sheet for accuracy of drug, frequency, duration, strength, and route, and to check physician orders if there is any discrepancy. In multiple instances, staff did not follow these procedures, resulting in residents receiving wrong medications, wrong doses, wrong dosage forms, and discontinued medications that had not been removed from circulation. One cognitively intact resident with orthostatic hypotension and neurocognitive disorder with Lewy bodies was given another resident’s medications after an RN left a medication cart unattended between two rooms and then returned and handed the wrong medications to the resident. The medications included Oxycontin ER 20 mg and Amlodipine 5 mg, and the resident subsequently required Narcan and hospitalization, with hospital records later documenting marked orthostatic blood pressure changes requiring IV electrolytes and hydration. Another resident admitted with multiple rib fractures had an order for Oxycodone 5 mg every 6 hours for pain that was discontinued and changed to Hydrocodone 5-325 mg; however, the discontinued Oxycodone was not removed from circulation, and the resident received the wrong opioid medication on a later date. A resident on hospice care with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of liquid on multiple dates. The Lorazepam was later discontinued but not removed from circulation, resulting in an additional dose being administered after discontinuation. Pharmacy review identified that another resident’s Tacrolimus dose was incorrectly transcribed in the medical record as 5 mg, two tablets twice daily instead of the ordered 0.5 mg, two tablets twice daily, and the resident received the wrong dose at morning administration. In separate incidents, one resident received another resident’s 40 mg Atorvastatin tablet, and another resident took another resident’s medications (gabapentin, clonidine, and Vitamin D) after medication cups were set at the bedside for two residents with the same initials, and one resident ingested the medications without checking the cup.
Failure to Timely Report Medication Error and Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report an incident of potential neglect to the state survey agency after a resident received the wrong medications, required Narcan, and was hospitalized. The facility’s abuse prevention policy defines possible neglect as the failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress, or that could reasonably be expected to cause pain, injury, or death. The resident involved was admitted with orthostatic hypotension and a neurocognitive disorder with Lewy bodies, and had a BIMS score of 14/15, indicating intact cognition, with an activated power of attorney for health care. On the date of the incident, a licensed nurse administered medications intended for another resident, including Oxycontin ER 20 mg and Amlodipine 5 mg, to this resident. The physician was contacted immediately, Narcan was ordered and administered, and the resident was sent to the emergency department for observation of the medication error. In the hospital, the resident was found to be markedly orthostatic and received IV electrolytes and hydration, and was later transferred to another hospital when blood pressure began trending low, before eventually returning to the facility. During an interview with the surveyor, the DON stated the incident was not reported to the state agency because it was the nurse’s first medication error and there were no noted signs or symptom effects of receiving the wrong medication, and acknowledged that the 5-day investigation was not submitted within the required 5 days.
Failure to Investigate and Correct Medication Errors Leading to Multiple Significant Drug Administration Mistakes
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and timely investigation and to implement corrective actions after an initial significant medication error, which allowed additional serious errors to occur. Facility policy on Medication Administration, revised 12/2025, requires accurate, safe, and timely administration of medications and verification of the medication label against the medication sheet, with physician orders checked if there is any discrepancy. Despite this, one resident admitted with multiple rib fractures was initially prescribed Oxycodone 5 mg every 6 hours for pain, which was discontinued and changed to Hydrocodone 5-325 mg every 6 hours on 06/26/25. On 07/02/25, this resident was administered the previously discontinued Oxycodone, which had not been removed from circulation. Following that event, the facility did not ensure that all licensed nurses were educated on medication administration requirements before their next shifts, and two further significant medication errors occurred. One cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER 20 mg and Amlodipine 5 mg, and required Narcan and transfer to the ED, where the resident was found to be markedly orthostatic and required IV electrolytes and hydration before transfer to another hospital when blood pressure trended low. Another cognitively intact hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder had been prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, which was discontinued on 06/19/25 but not removed from circulation. The controlled substance log showed that this resident repeatedly received the wrong dosage form (tablet instead of liquid) on multiple dates and again received the wrong form and a discontinued medication on 07/06/25. These events occurred while nurse management were aware of the initial error but had not yet ensured all licensed staff were educated prior to subsequent shifts.
Failure to Properly Destroy and Discontinue Controlled Substances
Penalty
Summary
The facility failed to ensure proper destruction and disposition of controlled substances for two residents, contrary to its policy requiring unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and with a witness to the destruction. For one resident, documentation showed an order for Pregabalin (Lyrica) 50 mg capsules twice daily that was later discontinued and changed to Pregabalin (Lyrica) 75 mg twice daily. The narcotic sheet for the 50 mg dose had an "X" across the sheet with a notation "Destroyed RN" and only one nurse’s signature. During interview, the DON stated that controlled substances should be discarded right away once it is known the resident will not be using them or when the provider discontinues the order, and acknowledged that the 50 mg Pregabalin should have been destroyed immediately and with two licensed staff, but was not. For another resident, Lorazepam oral concentrate 0.25 ml every four hours as needed for terminal anxiety was prescribed, but the facility’s controlled substance log initiated for this resident was labeled for Lorazepam 0.5 mg tablets. The log showed documentation that the resident continued to receive Lorazepam after the medication had been discontinued. In interviews, the DON and ADON acknowledged awareness of medication errors related to this situation. A registered nurse described the usual process for controlled substance destruction as using a drug buster in the medication storage room with two nurses signing off and verifying destruction, which contrasted with the documented practice in these cases.
Improper Labeling and Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored, and administered according to physician orders and facility policy for two residents. One resident with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was admitted on 03/21/25 and placed on hospice care on 06/02/25. On that date, the resident was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of the ordered liquid concentrate. The controlled substance log initiated on 06/02/25 was labeled for Lorazepam 0.5 mg tablets, and documentation showed the resident received the wrong dosage form on multiple dates (06/04/25, 06/05/25, 06/06/25, 06/09/25, and 06/10/25). Additionally, the Lorazepam was discontinued on 06/19/25 but was not removed from circulation, and the resident received an additional dose without a physician’s order on 07/06/25. In a separate incident, a surveyor observed an RN at the medication cart and asked about narcotic administration. The RN presented the narcotic box, where the surveyor observed a morphine bottle with no label identifying the resident, the correct dose, or other required information, only a handwritten “#36” in permanent marker. When questioned, the RN had to search through narcotic records to determine that the bottle belonged to another resident and confirmed that the morphine oral concentration bottle was not properly labeled with the resident’s name, date of birth, pharmacy dispense date, or other identifying information. The RN acknowledged that this morphine had been administered 13 times without proper labeling and stated they had not realized the resident’s name was missing from the bottle. The DON later stated that liquid medications, especially morphine, were expected to be correctly labeled and that unlabeled morphine should not be administered.
Inaccurate PBJ Staffing Data Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. Despite facility staff, including the DON and HR, stating that weekend staffing levels were consistent with weekday staffing and that call-ins did not differ between weekends and weekdays, the PBJ data submitted for multiple fiscal quarters indicated excessively low weekend staffing. Upon review, it was discovered that the process used by Corporate HR to pull and enter staffing data into the PBJ system was flawed. Specifically, if a staff member left employment before the data was pulled, their name and corresponding hours worked were deleted from the report, resulting in underreporting of actual hours worked. This underreporting led to inaccurate PBJ submissions, which triggered the facility to be flagged for low weekend staffing. The deficiency was identified through interviews with facility leadership and review of submitted PBJ data, schedules, and staff postings, which confirmed that multiple staff hours worked on weekends were not reported. This issue had the potential to affect all 71 residents residing in the facility, as the reported staffing levels did not accurately reflect the care provided.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with monoplegia of the upper limb and COPD was not provided reasonable accommodation for their needs, specifically regarding access to their call light. The resident's care plan required that the call light be kept within reach due to their risk for falls and limited mobility. However, during an observation, the resident was found sitting in a wheelchair with the call light wrapped around the far-left bedside rail, out of reach. The resident was heard yelling for help and reported that staff often forgot to place the call light within reach after transfers from bed to wheelchair. The resident's most recent assessment indicated intact cognition and a need for partial to moderate assistance with mobility. The facility's fall management policy required adequate supervision and assistive devices to minimize fall risk. Despite this, staff failed to ensure the call light was accessible, as confirmed by both the resident and the DON, who acknowledged staff awareness of the resident's limitations and the importance of call light accessibility.
Failure to Follow Wound Care Orders and Infection Control During Pressure Injury Treatment
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, end stage renal disease, diabetes mellitus type 2, peripheral vascular disease, and chronic venous insufficiency, was admitted to the facility with several pressure injuries (PIs) and diabetic foot ulcers. The resident was dependent on staff for most activities of daily living and was identified as being at risk for pressure injuries. Physician orders specified a detailed wound care regimen, including cleansing, application of skin prep, Santyl ointment, calcium alginate, and zinc oxide to specific areas, to be performed daily and as needed. During a surveyor's observation, a registered nurse failed to follow proper infection control protocols and did not adhere to the physician's wound care orders. The nurse entered the resident's room without performing hand hygiene, donned gloves, and proceeded with wound care without changing gloves or sanitizing hands between steps. The nurse also omitted key steps in the wound care process, such as applying skin prep and Santyl ointment before the calcium alginate, as ordered. These actions were confirmed by the Assistant Director of Nursing, who acknowledged that hand hygiene and adherence to wound care orders were not followed during the observed care.
Failure to Prevent Accidents and Inadequate Supervision for Residents at Risk
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with a history of cerebral infarction, severe cognitive deficit, generalized weakness, and osteoporosis was assessed as high risk for falls and required dependent assistance with toileting. Despite care plan interventions specifying that staff should remain with the resident while in the bathroom, the resident was left unsupervised for approximately 20 minutes, resulting in an unwitnessed fall. The resident was not observed to use the call light, and staff did not return to check on the resident during this period, contrary to the care plan and facility expectations. Another resident, who is cognitively intact but dependent on staff for toileting hygiene, lower body dressing, and transfers, was not properly assessed for independent vaping or smoking. Although the facility's policy requires an evaluation for all residents who use tobacco products or e-cigarettes, the resident was listed as able to smoke independently without a completed assessment or a care plan addressing vaping or smoking. The resident reported being able to go outside to vape, but the facility had not documented this in the care plan or completed the required assessment at the time of the survey. These deficiencies were identified through observation, interviews, and record reviews, which revealed lapses in following established policies and care plan interventions. The facility did not ensure that residents at risk for falls or those using tobacco products were adequately supervised or assessed, leading to preventable incidents and a lack of appropriate care planning.
Failure to Provide Ongoing Assessment and Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident who required dialysis services. According to the facility's own policy, staff are required to assess the resident's condition and monitor for complications before and after dialysis treatments, including checking vital signs, weight, and the status of the dialysis access site. However, review of the resident's medical record revealed that there was no documentation of comprehensive assessments, such as vital signs, weight, or inspection of the dialysis port site, either before or after the resident returned from dialysis. The medication and treatment administration records only showed weekly vital signs and weights, with no specific documentation related to pre- and post-dialysis care. Interviews with the resident and the Director of Nursing confirmed that staff did not consistently perform or document assessments upon the resident's return from dialysis. The resident reported that staff sometimes checked vital signs after dialysis, but not always immediately upon return. The DON acknowledged that staff did not document assessments after dialysis and that there was no established process for assessing the dialysis port site upon return, as some dialysis facilities preferred the bandage not be removed. The lack of ongoing assessment and monitoring was not consistent with the facility's policy or the resident's care plan.
Infection Control Lapses in Hand Hygiene, PPE Use, and Catheter Bag Management
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of medical devices. During wound care for a resident with multiple pressure injuries and diabetic foot ulcers, a registered nurse did not perform hand hygiene at required intervals, failed to use a gown as part of enhanced barrier precautions (EBP), and used personal supplies without proper disinfection. The nurse also placed contaminated items back into personal storage and did not sanitize equipment after use, contrary to facility policy and infection control standards. In another instance, a certified nursing assistant (CNA) did not perform hand hygiene after removing gloves during incontinence care for a resident, instead proceeding to handle clean items and assist with dressing without sanitizing hands. The CNA acknowledged the lapse when questioned and confirmed that hand hygiene should have been performed between glove changes, as required by facility policy. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag lying on the floor, despite facility policy stating that drainage bags should not touch the floor. Staff were seen handling the bag and placing it back on the floor, and the resident reported that the bag was always on the floor. The care plan for this resident did not address proper placement of the urinary collection bag, and staff interviews confirmed the expectation that the bag should be kept off the floor.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the storage, labeling, and dating of food items, which are essential to prevent foodborne illnesses. During a survey, multiple unlabeled and potentially expired food items were found in the facility's walk-in refrigerator and resident kitchenette. These included containers of Italian dressing, relish, whipping cream, milk, sour cream, and various dressings, some of which lacked open date labels or had expired manufacturer's dates. The Dietary Manager (DM) and Dietary staff admitted to not labeling items with open dates and acknowledged the presence of expired items. The surveyor observed that the facility's policy required all refrigerated and prepared food to be covered, labeled, and dated with a use-by date. However, this policy was not consistently followed, as evidenced by the presence of unlabeled and expired food items. The DM indicated that it was the responsibility of the kitchen staff to monitor the resident fridge, but this was not being done effectively. The DM also mentioned that nursing staff were expected to monitor the fridge, but this was not occurring, leading to expired food items being stored in the resident refrigerator. The Nursing Home Administrator (NHA) was unaware of any foodborne illnesses among staff and residents, but acknowledged the deficiency after being informed by the DM. The DM admitted to the NHA that items in the kitchen were not labeled with open dates and that expired items were found in the kitchen area. This lack of adherence to food safety protocols posed a risk of foodborne illness to the residents, although no illnesses were reported at the time of the survey.
Failure to Convey Deceased Resident's Trust Funds
Penalty
Summary
The facility failed to ensure the timely conveyance of a deceased resident's trust funds to the appropriate party. Specifically, the facility did not return the trust funds of a resident, identified as R1, to the Power of Attorney (POA) or family within 30 days of the resident's death. The facility's policy on Resident Trust Accounts mandates that upon a resident's death, the facility must promptly convey the resident's funds and provide a final accounting to the individual administering the resident's estate. However, a review of R1's account history revealed a positive balance of $180.11, with no documentation of funds being conveyed to the POA. During the survey, a family member of R1, identified as FM C, reported that the facility refused to refund the trust account balance, citing an outstanding balance of $5,000 owed by FM C. The Nursing Home Administrator (NHA) expressed uncertainty about the remaining balance, while the Accounts Receivable Specialist claimed that all trust accounts are typically conveyed within 30 days of discharge or death. Despite this assertion, the funds had not been returned, indicating a lapse in the facility's adherence to its policy and regulatory requirements.
Failure to Report Falls to Physician
Penalty
Summary
The facility failed to immediately report falls to the physician for two residents, leading to a deficiency in communication and care. The first resident, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite being found on the floor and examined for injuries, there was no documentation that the physician or family members were notified of the incident. An investigation later revealed that the nurse on duty did not inform the necessary parties, resulting in disciplinary action against the nurse. The second resident, with diagnoses including dementia and repeated falls, had two unwitnessed falls on 10/09/24 and 10/24/24. There was no documentation of physician notification for either incident. The Director of Nursing (DON) was unaware of the falls until observing the resident with facial bruising. The lack of documentation and communication with the physician regarding the resident's injuries and falls highlights a significant lapse in following the facility's change in condition policy.
Failure to Conduct Proper Assessments After Falls
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for two residents following falls. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall on 09/09/24. The resident was found on the floor tangled in bedding, but the nurse did not perform a thorough assessment, including vital signs, neurological checks, or a head-to-toe examination. The fall was not reported to hospice services or the family until the following day when the resident showed signs of pain and bruising, indicating a possible injury. Resident 2, diagnosed with dementia and at risk for falls, had an unwitnessed fall and another incident where they slid out of a wheelchair. Despite these events, there was no documentation of a comprehensive assessment, including vital signs or neurological checks, in the resident's records. The Director of Nursing was unaware of the falls until observing the resident with facial bruising, suggesting a lack of communication and documentation by the nursing staff. The facility's failure to conduct proper assessments and communicate falls to relevant parties resulted in deficiencies in maintaining the residents' highest practicable level of physical well-being. The lack of documentation and communication highlights a significant gap in the facility's fall management protocol, as outlined in their policy, which requires thorough assessments and timely reporting of falls to physicians and family members.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement new care planned fall interventions for three residents who were at risk for falls. Resident 1, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite a discussion on 09/11/24 to add a fall mat as a new intervention, this was not added to the care plan, and no other interventions were updated following the fall. Resident 2, with diagnoses including dementia and repeated falls, had two falls on 10/09/24 and 10/24/24. The facility did not implement any new interventions after these incidents, despite the resident's care plan being in place since 04/22/24. The care plan included various interventions, but none were updated or added following the falls. Resident 3, who had a history of falling and other medical conditions, fell on 10/21/24. The care plan, initiated in 2018, was not updated with new interventions after the fall. The Director of Nursing acknowledged that no new interventions were implemented for any of the residents after their falls, citing that staff sometimes miss implementing new interventions.
Improper Hand Hygiene and Hair Net Use in Food Service
Penalty
Summary
The facility did not ensure proper hand hygiene and use of hair nets in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a Certified Nursing Assistant (CNA) was observed entering the kitchen without wearing a hair net, despite a sign indicating that hair nets were required. The CNA indicated they were just grabbing coffee, but their uncovered hair could easily fall into the coffee cup, which was located near the cooking and plating areas of the kitchen. Additionally, during the point of service plating before lunch, a Dietary Cook (DC) was observed using gloves to place bread on residents' plates. However, the DC touched their glasses and stove controls without changing gloves or using hand hygiene before continuing to handle the bread. The Dietary Manager (DM) confirmed that they would expect anyone entering the kitchen to wear a hair net and that staff should use tongs or change gloves and wash hands if unclean items are touched during the serving process.
Failure to Schedule Follow-Up Oncology Appointment
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to follow physician orders to schedule a follow-up oncology appointment within 2-4 days after admission for a resident diagnosed with a lesion on the left ninth rib, which could represent metastatic disease. The hospital discharge summary clearly indicated the need for this follow-up, but the facility did not act on these orders in a timely manner. The facility's admission checklist required multiple checks and signatures to ensure all orders were followed, but this process was not effectively executed. The Social Services Assistant, responsible for scheduling appointments, did not receive the necessary information to schedule the oncology follow-up. Interviews with staff, including the DON and RN, revealed that the facility's procedure for scheduling appointments was not followed, and there was confusion about the responsibility for ensuring the appointment was made. The resident confirmed awareness of the oncology referral but was unsure if the appointment had been scheduled. The DON and other staff members acknowledged the oversight and indicated that the facility was waiting for insurance authorization, which had not been communicated effectively. There was no documentation of attempts to schedule the appointment or communicate with other providers until the surveyor's review, indicating a lapse in the facility's protocol and communication processes.
Failure to Supervise Resident During Use of Oscillating Percussion Vest
Penalty
Summary
The facility did not evaluate for hazards or risks related to the use of an oscillating percussion vest for a resident with quadriplegia and a high risk for aspiration. The resident, who has a history of aspiration pneumonia and other severe medical conditions, was observed alone in his room wearing the vest without supervision. The care plan did not address whether the resident was safe to be left alone with the vest or how supervision would be provided during the treatment sessions. Staff interviews revealed that the resident was unable to use a call light to ask for assistance, and there was no clear protocol for ensuring the resident's safety during the vest treatment. The resident's physician orders included the use of the Afflo Respiratory Vest twice daily while sitting up in a wheelchair, with specific instructions to stop tube feeding during the session and check the resident's mouth and lung sounds afterward. However, observations and staff interviews indicated that these orders were not consistently followed. For instance, the surveyor did not observe nursing staff checking the resident's lung sounds after a vest session, and the resident had a large amount of mucus in his mouth that required oral care. The Director of Nursing (DON) confirmed that the resident's care plan did not initially include the use of the chest vest and that an assessment to determine if the resident was safe to wear the vest unsupervised had not been conducted. Despite the manufacturer's instructions indicating that disabled persons should not use the vest without supervision, the facility did not have a clear protocol for supervising the resident during vest treatments. Staff reported that they usually kept the resident by the nurse's station or left his door open for observation, but this was not documented in the care plan or consistently practiced.
Improper Verification of G-Tube Placement During Medication Administration
Penalty
Summary
The facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with one resident who received medication without ensuring the G-tube was appropriately placed prior to medication administration. The resident, who had diagnoses of epilepsy, cerebral palsy, and functional intestinal disorder, was observed receiving valproic acid via G-tube without proper verification of tube placement according to current standards of practice. The Licensed Practical Nurse (LPN) administering the medication used an outdated method of injecting air into the G-tube and listening for noise to check for proper placement. This method is no longer the standard of practice, as confirmed by the surveyor and the Director of Nursing (DON). The facility's policy, last revised in March 2020, still included this outdated practice, leading to the deficiency observed during the survey.
Infection Control Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff failed to perform proper hand hygiene during medication administration with a resident who had a severe cognitive impact. Specifically, a registered nurse did not perform hand hygiene before and after administering medications to the resident and proceeded to check another resident's blood sugar without proper hand hygiene initially. This was observed by a surveyor and confirmed by the Director of Nursing, who acknowledged that the nurse should have performed hand hygiene between residents. Additionally, the facility prematurely removed droplet precautions for a resident who tested positive for COVID-19. The resident was supposed to remain on droplet precautions for ten days following the onset of symptoms, but staff miscounted the isolation days, leading to the removal of precautions one day early. This error was identified when the surveyor observed the resident on contact precautions instead of droplet precautions. The Assistant Director of Nursing confirmed that the miscalculation occurred because staff did not count the first day of isolation as day zero, resulting in the premature removal of droplet precautions.
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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.
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Nursing homes near Chetek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barron Care And Rehabilitation | 11.4 mi | — | 19 | 0 |
| Heritage Lakeside | 14.2 mi | — | 15 | 1 |
| Dove Healthcare - Rice Lake | 14.5 mi | — | 1 | 0 |
| Dove Healthcare - Bloomer | 16.4 mi | — | 1 | 0 |
| Meadowbrook At Bloomer | 16.9 mi | — | 0 | 0 |
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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 August 2026) and official state health department websites.