Meadowbrook at Black River Falls

In the surveyor’s words

From the most serious findings on record at Meadowbrook at Black River Falls, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 16, 2024

  Based on record review and interview, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (R187) reviewed for accidents. R187 had an elopement from the hospital prior to admission and, following admission here, eloped from the building on 3 separate occasions. On the second elopement, R187 was missing for 2.5 hours, which required police and a K9 search to find R187. On the third elopement, R187 traveled 1.4 miles to a bridge, running through busy traffic, and attempted to jump off the bridge. Facility failure to provide adequate supervision created a finding of immediate jeopardy that began on 08/23/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/09/24 at 1:00 PM. […]

• Immediate jeopardy, isolatedF686Jul 10, 2024

  Based on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R6) at high risk for pressure ulcer development, received the necessary treatment and services needed to prevent the development of a pressure injury. R1 was admitted to the facility with a brace and ace bandage on her leg. R1 was identified as being at risk for pressure injuries and a care plan was not developed. The facility did not assess the skin under the brace/ace bandage routinely, which lead to multiple pressure injuries. […]

• Immediate jeopardy, isolatedF689Oct 4, 2022

  Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care (APOAHC). R1 eloped from the facility on 8/31/22. On 9/12/22, R1 eloped again and was found by a member of the community by the road near the facility. The facility did not have a care plan in place for R1 detailing how the facility would keep R1 safe and prevent future elopements. The facility's failure to provide adequate supervision to R1 and ensure all the alarmed doors were armed created a finding of Immediate Jeopardy which began on 9/12/22. […]

• Immediate jeopardy, isolatedF684Aug 30, 2021

  Based on staff interview and record review the facility did not ensure 1 of 1 residents (R1) reviewed received appropriate care and treatment to prevent the development of a non-pressure related wound, promote healing of the wound, and prevent infection of the non-pressure related wound. R1 was admitted to the facility without non-pressure wounds on R1's left foot. R1 had historical [CONDITION(S)] of the right foot which had resulted in a below the knee amputation. On 7/9/21 R1 developed shearing on the left third toe. […]

• Immediate jeopardy, isolatedF686Aug 30, 2021

  Based on observation, interview, and record review the facility did not ensure one of one residents reviewed with a pressure injury (R2) received the necessary care and treatment to promote healing and prevent infection. R2 was admitted to the facility on [DATE] from the hospital with a Stage II pressure injury requiring an IV (Intravenous) antibiotic due to pseudomonas [CONDITION(S)]. The facility did not; ~ Recognize, identify or assess risk factors related to R2's pressure injury; ~ Develop, evaluate, and revise R1's care plan based on R2's risk factors and needs; ~ Recognize, assess, and timely and accurately document comprehensive wound assessments as indicated by the change in condition and deterioration of R2's pressure injury; ~ Update R1's physician timely and when decline was… […]