Meadowbrook at Oconto Falls

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 15, 2021

  Based on observation, staff interviews, and record review, the facility did not implement an infection control policy to effectively prevent and/or contain the spread of COVID-19 infection. The practices had the potential to affect all 35 residents. The facility did not exclude seven (7) staff (Therapy Staff (TS)-F, Registered Nurse (RN)-G, TS-H, RN-I, Certified Nursing Assistant (CNA)-J, CNA-K, and CNA-L) from work while they were experiencing COVID-19 symptoms; staff attributed symptoms to other causes and not all COVID-19 symptoms per current Centers for Disease Control and Prevention (CDC) guidance were included on the facility screening tool. […]

• Immediate jeopardy, isolatedF600Dec 16, 2024

  Based on observation, staff, resident, resident representative interview, and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R2) of 10 sampled residents. R9 had a history of sexually inappropriate behavior toward residents and staff. R2 had a history of wandering in and out of residents' rooms unsupervised. On 10/23/24, R10 reported to R2's Guardian (GDN-O) that R9 had groped R2's breast in the dining room. GDN-O reported the allegation to Nursing Home Administrator (NHA)-A. […]

• Actual harm, isolatedF689May 21, 2024

  Based on staff interview and record review, the facility did not ensure the provision of a safe environment that was free of accident hazards for 1 resident (R) (R1) of 5 sampled residents. On 5/17/24, R1 reported to staff that R1 fell out of a Hoyer lift when Certified Nursing Assistant (CNA)-C transferred R1 alone. On 5/18/24, R1 went to the hospital and was diagnosed with a left hip fracture. In addition, staff did not adequately assess R1 following R1's reported fall and had increased pain which delayed R1's diagnosis. […]

• No harm, potential for more than minimal, widespreadF727May 21, 2024

  Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 51 residents residing in the facility. The facility did not have an RN on duty from 5/17/24 at 6:05 PM until 5/19/24 at 12:00 PM. Findings include: On 5/21/24, Surveyor reviewed the facility's assessment, revised 5/14/24, that indicated the facility will have an RN on duty at least 8 consecutive hours per day 7 days per week. On 5/21/24, Surveyor reviewed the facility's waivers. The facility did not have a waiver related to staffing or having an RN on duty. On 5/21/24, Surveyor reviewed the facility's schedules and time sheets from 5/17/24 through 5/20/24. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2024

  Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. The facility did not maintain an infection tracking and surveillance log which had the potential to affect all 50 residents residing in the facility. In addition, staff did not perform appropriate hand hygiene or sanitize equipment during the provision of cares for 2 residents (R) (R30 and R4) of 2 residents and did not don appropriate personal protective equipment (PPE) for 1 (R2) of 2 residents on transmission-based precautions. […]