Meadowbrook at Black River Falls
1311 Tyler St · Black River Falls, WI · 54615 · 7152844396
45 certified beds For profit - Corporation Chain: Synergy Senior Care
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $108,338 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$108,338 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
71% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 4.23 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.21 | 0.55–0.75 |
| Weekend hours / resident-day | 3.69 | ≈ weekday level |
| Nursing turnover / year | 71% | median 45% |
| Fines (3-yr window) | 3 · $108,338 |
Inspection citations (39 in the current record)
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Potential for harm · E January 14, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected February 14, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E January 14, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected February 14, 2026 · Resident Rights
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Potential for harm · D January 14, 2026
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected February 14, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 14, 2026
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected February 14, 2026 · Pharmacy Service
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Potential for harm · F January 14, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 14, 2026 · Nutrition and Dietary
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Potential for harm · F January 14, 2026
Provide and implement an infection prevention and control program.
Corrected February 14, 2026 · Infection Control
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Potential for harm · D October 22, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 11, 2025 · Quality of Life and Care
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Potential for harm · D April 1, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected April 23, 2025 · Quality of Life and Care
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Actual harm · G January 22, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected March 24, 2025 · Pharmacy Service
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Potential for harm · D January 22, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 16, 2025 · Pharmacy Service
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Potential for harm · D January 22, 2025 · found via complaint
Ensure 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.
Corrected February 16, 2025 · Pharmacy Service
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Potential for harm · F December 18, 2024 · found via complaint
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected December 23, 2024 · Nutrition and Dietary
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Potential for harm · F December 18, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 23, 2024 · Nutrition and Dietary
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Potential for harm · D December 18, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 23, 2024 · Infection Control
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No harm found · C December 18, 2024 · found via complaint
Post nurse staffing information every day.
Corrected December 23, 2024 · Nursing and Physician Services
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Immediate jeopardy · J October 16, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 27, 2024 · Quality of Life and Care
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Potential for harm · D October 16, 2024
Honor 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.
Corrected November 11, 2024 · Resident Rights
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Potential for harm · D October 16, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected November 11, 2024 · Resident Rights
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Potential for harm · D October 16, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected November 11, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 11, 2024 · Resident Rights
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Potential for harm · D October 16, 2024
Notify 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.
Corrected November 11, 2024 · Resident Rights
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Potential for harm · D October 16, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected November 11, 2024 · Quality of Life and Care
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Potential for harm · D October 16, 2024
Ensure 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.
Corrected November 11, 2024 · Quality of Life and Care
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Potential for harm · D October 16, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 11, 2024 · Quality of Life and Care
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Potential for harm · D October 16, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 11, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 22, 2025 | Fine | $56,898 |
| January 22, 2025 | Payment Denial | 32 days |
| October 16, 2024 | Fine | $17,250 |
| July 10, 2024 | Fine | $34,190 |
| July 10, 2024 | Payment Denial | 36 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525488 · certified since May 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.