Meadowbrook at Chetek

In the surveyor’s words

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

• Actual harm, isolatedF760Feb 3, 2026

  Based on interview and record review the facility did not ensure that a system is in place to ensure that residents are free of any significant medication error for 6 of 9 residents (R) (R1, R3, R5, R7, R8, and R9) reviewed for medication errors.R1 is cited at a scope and severity level of G (actual harm that is not immediate jeopardy/isolated). R1 was administered R2's medications, which required R1 to receive Narcan and hospitalization. R3 was administered incorrect pain medication.R5 was administered medication that was discontinued and wrong dosage form.Pharmacy found that R7 had the wrong dose in the medical record for R7's Tacrolimus.R8 received a different resident's 40 mg tab of Atorvastatin. […]

• No harm, potential for more than minimal, widespreadF880May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure a comprehensive infection prevention and control program was established and maintained. Specifically, the facility failed to ensure staff used Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP), sanitize mechanical lifts between resident use, complete proper hand hygiene, or provide residents with hand-hygiene before meals.-Registered Nurse (RN) C and Licensed Practical Nurse (LPN) D entered R23's room and conducted wound care on R23's open leg wounds without donning PPE prior to and during wound care treatment, having the ability to potentially spread infection to all 75 residents in the facility.-Certified Nursing Assistant (CNA) R and LPN D did not wear PPE while transferring R4… […]

• No harm, potential for more than minimal, widespreadF851Mar 19, 2025

  Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 71 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness for 57 of 59 residents reviewed. Findings include: Facility policy titled Storage, Prepare, Distribute, and Serve Food, last revised [DATE], stated in part, .-#3. Storage (Refrigerated) c. All refrigerated and prepared food must be covered, labeled, and dated with use-by date . Facility policy titled Labeling Food and Date Marking, last revised February 2020, stated in part, .-#2. Recommended that all items placed in refrigeration units be labeled with the name of the item, the date the item is placed in the refrigerator and/or the date it is to be used .-#6. […]

• No harm, potential for more than minimal, widespreadF880Mar 29, 2023

  Based on observations, staff interview and record review, the facility failed to properly prevent COVID-19 and other infectious diseases. This practice had the potential to affect all 60 residents residing in the facility. The facility did not implement infection control processes to prevent a COVID-19 outbreak. Signs posted at the entrance of the facility for visitors had incorrect COVID-19 Community Transmission data to base source control for visitors. Visitors were allowed throughout facility without proper source control when the county was in a high transmission rate and during a COVID-19 outbreak. […]