Inspection Reports for Meadowbrook Senior Living at Black River Falls

109 NORTH 14TH STREET, BLACK RIVER FALLS, WI, 54615

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 7.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

59% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

Census

Latest occupancy rate 44% occupied

Based on a July 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

7 14 21 28 35 42 Nov 2023 Jan 2024 Aug 2024 Jan 2025 Jul 2025
Inspection Report Complaint Investigation Deficiencies: 1 Jul 28, 2025
Visit Reason
A complaint investigation was conducted on July 28, 2025, to determine if Meadowbrook Senior Living at Black River Falls was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #44PQ11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture of $450.
Complaint Details
The complaint investigation concluded that the facility was not in substantial compliance with applicable statutes and administrative codes, leading to enforcement action including a forfeiture.
Deficiencies (1)
Description
Violation of Wis. Admin. Code ch. DHS 83.44(2)(a) as identified in SOD #44PQ11
Report Facts
Forfeiture amount: 450 Reduced forfeiture amount: 292.5 Forfeiture payment timeframe: 10 Compliance timeframe: 45 Inspection fee: 200
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
William R. GardnerAssisted Living Regional DirectorContact person for questions about the letter
Inspection Report Complaint Investigation Census: 14 Capacity: 32 Deficiencies: 6 Jul 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns regarding medication management and other facility issues at Meadowbrook Senior Living at Black River Falls.
Findings
Six deficiencies were identified, including failure to notify the department of an administrator change within 7 days, inadequate proof-of-use records for controlled substances, medication errors and lack of communication with prescribing practitioners, incomplete documentation of medication administration, unclean rooms with strong urine odors, and unsafe use of extension cords in place of permanent wiring.
Complaint Details
The complaint was substantiated. It involved medication management issues including missing narcotics, lack of audits, and failure to notify providers of medication errors or refusals.
Deficiencies (6)
Description
Licensee did not notify the department within 7 days after a change in the administrator.
Facility did not maintain a proof-of-use record for schedule II drugs audited, signed, and dated daily by the administrator or designee.
Provider did not notify Resident 5's prescribing practitioner, nurse, or pharmacist when medication was not received for 2 or more consecutive days.
Person administering medication did not document name, dosage, date and time of medication taken, and initial the medication administration record.
Rooms were not clean and free from odors; strong smell of urine was noted in the south hallway.
Extension cords were used in lieu of permanent wiring in a shared bathroom.
Report Facts
Deficiencies identified: 6 Repeat deficiencies: 2 Licensed capacity: 32 Resident census: 14 Medication administration record (MAR) blank spaces: 6 Handwritten initials on MAR: 19
Employees Mentioned
NameTitleContext
Administrator AAdministratorInterviewed regarding administrator change, medication management issues, and facility deficiencies.
Wellness Director DWellness DirectorTerminated due to failure to complete medication audits and supervise medication administration.
Caregiver CCaregiverObserved performing housekeeping duties and interviewed about cleaning tasks.
Maintenance Person BMaintenance PersonInterviewed regarding use of extension cord in shared bathroom.
Inspection Report Complaint Investigation Census: 19 Deficiencies: 0 Jan 14, 2025
Visit Reason
Surveyor completed a complaint investigation and verification visit at Meadowbrook Senior Living at Black River Falls.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the visit.
Complaint Details
The complaint was unsubstantiated.
Report Facts
Revisit fee: 200
Inspection Report Complaint Investigation Deficiencies: 1 Aug 14, 2024
Visit Reason
A complaint investigation and verification visit was conducted to determine if Meadowbrook Senior Living at Black River Falls was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #XP5112) for violations related to the facility's failure to maintain a clean and odor-free environment. Enforcement actions include an order to comply, special orders for corrective measures, and a forfeiture of $300.
Complaint Details
The visit was complaint-related, conducted to verify compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The Department found violations and issued a Statement of Deficiency #XP5112.
Deficiencies (1)
Description
Failure to maintain a home that is clean and free from odors.
Report Facts
Forfeiture amount: 300 Reduced forfeiture amount: 195 Inspection fee: 200 Compliance timeframe: 45 Payment timeframe: 10 Posting duration: 90
Employees Mentioned
NameTitleContext
William R. GardnerAssisted Living Regional DirectorContact person for questions about the letter.
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter.
Inspection Report Complaint Investigation Census: 18 Deficiencies: 1 Aug 14, 2024
Visit Reason
Surveyors conducted a verification visit and four complaint investigations at Meadowbrook Senior Living at Black River Falls. The complaints were unsubstantiated.
Findings
One deficiency was identified related to rooms not being clean and free from odors, specifically a strong smell of urine and a stain near Resident 1's room. The deficiency was a repeat violation. Caregivers did not address the odor or stain promptly, and the room was not scheduled for cleaning that day.
Complaint Details
The visit was complaint-related with four complaints investigated and found unsubstantiated.
Deficiencies (1)
Description
The provider did not ensure all rooms were free from odors; there was a strong smell of urine in the south hallway and a reddish-brown stain near Resident 1's room that was not cleaned promptly.
Report Facts
Revisit fee: 200 Number of complaints investigated: 4
Employees Mentioned
NameTitleContext
Wellness Director AWellness DirectorDiscussed concerns about Resident 1 and acknowledged issues with room inspections and policy adherence.
Administrator BAdministratorDiscussed concerns with surveyors regarding the deficiency.
Caregiver CObserved entering Resident 1's room but did not clean the stain, address the odor, or fix Resident 1's clothing.
Caregiver DCleaned the stain after being informed it had been present for approximately two hours.
Inspection Report Complaint Investigation Census: 24 Deficiencies: 7 Jan 25, 2024
Visit Reason
Surveyors conducted a complaint investigation triggered by five complaints regarding medication errors and other care concerns at Meadowbrook Senior Living at Black River Falls.
Findings
Five complaints were substantiated with seven deficiencies identified, including medication administration failures for Residents 2 and 3, failure to update Resident 1's individual service plan annually, lack of annual evacuation evaluation for Resident 1, failure to conduct an annual onsite medication administration review in 2023, incomplete documentation of medication administration, improper delegation and supervision of medication administration tasks, and failure to maintain rooms free from odors.
Complaint Details
Five complaints were investigated and all five were substantiated, including medication errors and failure to administer medications as prescribed.
Deficiencies (7)
Description
Provider did not ensure Resident 2 and Resident 3 received all prescribed medications as ordered.
Resident 1's individual service plan was not updated annually or when there was a change and was not signed by Resident 1.
Resident 1 was not evaluated annually for mental or physical capability to respond to a fire alarm.
Provider did not arrange for an annual onsite review of medication administration and storage systems in 2023.
Medication administration records (MAR) lacked documentation of the person administering medications and had numerous unsigned entries.
Caregivers administering injectables, nebulizers, and enteral medications were not properly delegated or supervised by licensed nurses.
Facility rooms were not kept free from odors; a strong urine odor was noted in the south hallway near Resident 1's room.
Report Facts
Deficiencies identified: 7 Repeat deficiencies: 3 Census: 24 Medication administration unsigned instances: 30 Medication administration unsigned instances: 85 Medication administration unsigned instances: 11 Medication not administered days: 22 Medication not administered days: 4
Employees Mentioned
NameTitleContext
Administrator BInterviewed regarding medication administration failures and delegation issues.
Registered Nurse CRegistered NurseInterviewed regarding medication administration, delegation, and supervision; involved in medication administration review.
Caregiver ACaregiverInterviewed about medication administration failures and refusals; stated delegation and supervision issues.
Caregiver DCaregiverInterviewed about lack of delegation and supervision for medication administration tasks.
Inspection Report Complaint Investigation Deficiencies: 4 Jan 24, 2024
Visit Reason
A complaint investigation was conducted on January 24, 2024, to determine if Meadowbrook Senior Living at Black River Falls was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #XP5111) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $1000 for specific code violations.
Complaint Details
The visit was complaint-related, concluding a complaint investigation on January 24, 2024, to assess compliance with applicable statutes and administrative codes.
Deficiencies (4)
Description
Violation of DHS Code 83.32(3)(h)
Violation of DHS Code 83.35(3)(d)
Violation of DHS Code 83.35(5)(b)
Violation of DHS Code 83.44(2)(a)
Report Facts
Forfeiture amount: 1000 Forfeiture amount: 400 Forfeiture amount: 300 Forfeiture amount: 150 Forfeiture amount: 150 Days to achieve compliance: 45 Days to request extension: 10 Days to pay forfeiture: 10 Reduced forfeiture amount: 650
Employees Mentioned
NameTitleContext
William R. GardnerAssisted Living Regional DirectorContact person for questions about the letter
Kenneth BrotheridgeAssisted Living DirectorSigned the Notice and Order letter
Inspection Report Complaint Investigation Deficiencies: 0 Nov 10, 2023
Visit Reason
A standard survey and complaint investigation was conducted to determine if Meadowbrook Senior Living at Black River Falls was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Findings
The Department issued a Statement of Deficiency (SOD #PBMY11) for violations of Wisconsin Statutes chapter 50 and Administrative Code chapter DHS 83, establishing grounds for regulatory action against the facility.
Complaint Details
The visit was complaint-related as it included a complaint investigation; however, the substantiation status is not stated.
Employees Mentioned
NameTitleContext
Kenneth BrotheridgeAssisted Living DirectorSigned the notice letter as the Assisted Living Director.
William R. GardnerAssisted Living Regional DirectorContact person for questions about the letter.
Inspection Report Complaint Investigation Census: 27 Capacity: 32 Deficiencies: 2 Nov 8, 2023
Visit Reason
The surveyor conducted a complaint investigation and a standard licensure survey on 11/08/2023. The complaint was not substantiated.
Findings
Two deficiencies were identified: a strong smell of urine and body odor in one hall due to a resident frequently refusing showers and being incontinent, and failure to conduct semi-annual emergency evacuation drills other than fire drills in 2022.
Complaint Details
The complaint investigation conducted on 11/08/2023 was not substantiated.
Deficiencies (2)
Description
The provider did not ensure all rooms were free from odors; a strong smell of urine and body odor was present in a hallway near a resident room.
The provider did not ensure emergency evacuation drills other than fire drills were conducted semi-annually in 2022.
Report Facts
Census: 27 Total licensed capacity: 32 Deficiencies identified: 2 Emergency evacuation drills conducted in 2022: 1
Employees Mentioned
NameTitleContext
Administrator AAdministratorInterviewed regarding odor and emergency evacuation drills
Medication Passer BMedication PasserInterviewed about odor in the hallway
Maintenance Person CMaintenance PersonInterviewed about emergency evacuation drills

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