A list of the most recent deficiencies for Meadowbrook of Black River Falls. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-17 | 2024-01-31 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-10-17 | 2024-01-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-10-17 | 2023-12-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-18 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-11-10 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-18 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-11-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-18 | 2023-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-15 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-04 | 2022-10-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-09-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-24 | 2022-09-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-24 | 2022-09-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-08-24 | 2022-09-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-24 | 2022-09-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-24 | 2022-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-24 | 2022-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-24 | 2022-09-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-24 | 2022-09-24 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-24 | 2022-09-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-24 | 2022-09-24 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-08-24 | 2022-09-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-24 | 2022-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-23 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-14 | 2022-07-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-14 | 2022-07-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-14 | 2022-07-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-04-06 | 2022-05-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-06 | 2022-05-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-06 | 2022-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-06 | 2022-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-06 | 2022-05-06 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-06 | 2022-05-06 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-06 | 2022-05-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-19 | 2021-11-05 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-19 | 2021-11-05 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-07 | 2021-10-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-30 | 2021-10-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-30 | 2021-10-04 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-08 | 2021-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-08 | 2021-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-08 | 2021-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-08 | 2021-08-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-23 | Not Fixed | N |
