Meadowbrook at Black River Falls, Black River Falls, WI

The Essentials

Summary

Across 9 inspections from October 2023 to January 2026, state surveyors documented 39 findings at Meadowbrook at Black River Falls; 39 have a recorded correction; CMS lists 5 enforcement actions in the window.

Inspections: 9; 2023–2026, standard and complaint
Findings: 39; Deficiencies cited by state inspectors
Corrected: 39; Of 39 findings, with a recorded correction date
Penalties: 5; 3 fines; payment not published, 2 closed

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2023	1	5	0
2024	4	23	2
2025	3	5	1
2026	1	6	0

What the Record Shows

39 of 39 findings have a recorded correction date.
CMS lists 5 enforcement actions in the window: 3 fines totaling $108,338, their payment not published; denial of payment imposed January 22, 2025, ended March 24, 2025; denial of payment imposed July 10, 2024, ended September 11, 2024.
8 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, January 14, 2026, recorded 6 findings (most serious: Level F).

What to Ask About

Kitchen and Food Safety, Cited in Four Inspections
Infection Control, Cited in Four Inspections
Medication Labeling and Storage, Cited in Three Inspections
Telling Families About Changes, Cited in Two Inspections
Reporting Suspected Abuse, Cited in Two Inspections
Pharmacy Services, Cited in Two Inspections

Report at a Glance

Facility: Meadowbrook at Black River Falls
Address: 1311 Tyler St, Black River Falls, WI 54615
CMS Certification Number: 525488
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 45
Ownership: For profit - Corporation
Record Window: October 18, 2023 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Jan 142026
Standard health inspection
6 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 14, 2026
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 14, 2026
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level ENo actual harm, potential for moreCorrected Feb 14, 2026
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Feb 14, 2026
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Feb 14, 2026
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Feb 14, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 222025
Complaint investigation
1 finding
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 12025
Complaint investigation
1 finding
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Apr 23, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jan 222025
Complaint investigation
3 findings
- F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Mar 24, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Dec 182024
Complaint investigation
4 findings
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level FNo actual harm, potential for moreCorrected Dec 23, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Dec 23, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 23, 2024
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Dec 23, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 162024
Standard health inspection
16 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Aug 27, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 11, 2024
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Nov 11, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
Enforcement Action
Civil money penalty, $17,250 imposed October 16, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 16, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $56,898 imposed January 22, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 16, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed January 22, 2025. Status: Closed, March 24, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 16, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 102024
Complaint investigation
2 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Sep 11, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Sep 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 42024
Complaint investigation
1 finding
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected May 3, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 182023
Standard health inspection
5 findings
The same visit included a complaint investigation.
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 10, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 10, 2023
- F814Dispose of garbage and refuse properly.Level CPotential for minimal harmCorrected Nov 10, 2023
Enforcement Action
Civil money penalty, $34,190 imposed July 10, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 18, 2023, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed July 10, 2024. Status: Closed, September 11, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 18, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Kitchen and Food Safety, Cited in Four Inspections
Inspectors cited F812 in October 2023, October 2024, December 2024 and January 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F812 across all 9 inspections, oldest to newest
2
Infection Control, Cited in Four Inspections
Inspectors cited F880 in October 2023, October 2024, December 2024 and January 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F880 across all 9 inspections, oldest to newest
3
Medication Labeling and Storage, Cited in Three Inspections
Inspectors cited F761 in October 2023, October 2024 and January 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F761 across all 9 inspections, oldest to newest
4
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in April 2024 and October 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F580 across all 9 inspections, oldest to newest
5
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in October 2023 and October 2024. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F609 across all 9 inspections, oldest to newest
6
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in October 2024 and January 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242425252526F755 across all 9 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in four inspections, most seriously at level F.
02
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level F.
03
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level D.
04
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level D.
05
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
06
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level D.
07
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
08
What led to the 2025 fine, and has it been paid?
A $56,898 civil money penalty was imposed January 22, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 18, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Apr 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jul 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Dec 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jan 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Apr 1, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Jan 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 525488
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowOctober 18, 2023 – October 1, 2026

CMS publishes about three inspection cycles; inspections before October 2023 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.