Meadow Brook Rehabilitation and Nursing

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine washing temperature was not reaching the required temperature, uncooked meat was stored with cooked foods, and the shelf above the steam table was soiled.

Inspectors wroteBased on observation and interview, the facility was not clean, comfortable and homelike. Specifically, there was no process for cleaning dirty wheelchairs and mechanical lifts. In addition, there was a medication cart in the dining room that was soiled with dead bugs in it. Resident identifiers: 1 and 11.

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 29 sampled residents, residents that had labs completed did not have those lab reports in their medical record. Resident identifiers: 3, 15, and 17.

Inspectors wroteBased on observation and interview, the facility did not serve food that was palatable. Specifically, for 4 out of 29 sampled residents, residents complained of the palatability of the food and a test tray was not palatable. Resident identifiers: 2, 5, 13, and 25.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were offered the Coronavirus disease 2019 (COVID-19) vaccines. Specifically, for 3 out of 5 sampled residents, no documentation was located to demonstrate how the residents accepted or refused the COVID-19 vaccination. Resident identifiers: 2, 6, and 31.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident was free from abuse and neglect. Specifically, for 1 out of 29 sampled residents, a resident was left in a sling unattended by staff and the same resident experienced staff yelling at them. Resident identifiers: 15 and 18.

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving abuse or neglect were reported immediately, but not later than 24 hours if the events that caused the allegations did not involve abuse. Specifically, for 1 out of 29 sampled residents, the facility did not report within the timeframe when a resident was left in a sling unattended by staff and experienced staff yelling at them. Resident identifier: 15.

Inspectors wroteBased on interview and record review, the facility did not provide the State Long-Term-Care Ombudsman notification when a resident was discharged from the facility. Specifically, for 1 out of 29 sampled residents, a resident left Against Medical Advice (AMA) and the ombudsman was not notified. Resident identifier: 35.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 29 sampled residents, a resident who had experienced a significant weight loss did not have recommendations from the Registered Dietitian (RD) implemented and the recommendations were not implemented in a timely manner. Resident identifier: 1.

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, for 1 out of 29 sampled residents, a resident that had a physician's order to collect a glycated hemoglobin (A1c) did not have the A1c completed. Resident identifier: 17.

Inspectors wroteBased on interview and record review, the facility did not provide or obtain laboratory (lab) services only when ordered by a physician. Specifically, for 1 out of 29 sampled residents, a resident did not have a physician's order for an ammonia level, Complete Blood Count (CBC), and magnesium. Resident identifier: 15.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received food prepared in a form designed to meet individual needs. Specifically, for 1 out of 29 sampled residents, a resident with a physician order for thickened liquids was not provided the appropriate thickened liquids. Resident identifier: 15.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 13 sampled residents, that the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, staff were not monitoring oxygen levels for a resident who had a diagnosis of pneumonia. Resident identifier: 1.

Inspectors wrote9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], Resident 93 was admitted to the facility. Resident 93 ' s Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93 ' s admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, Resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple areas of immediate jeopardy and harm were identified on the recertification survey. Resident identifiers: 3, 6, 17, 19, 21, 28, 29, 31, 34, 39, 90, 91, 92, 93, 94, 96, and 97.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 40 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, one resident with an advanced health care directive received treatment that was documented as against the resident's wishes. This resulted in a finding of harm. Resident identifier: 39.

Inspectors wroteBased on interview and record review, the facility did not provide and document sufficient preparation to 2 of 40 sampled residents to ensure safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment was discharged to a hotel room, but was subsequently seen at a local emergency room after becoming lost. This resulted in a finding of harm. In addition, one resident left on a leave of absence, and was not oriented for discharge upon return to the facility. Resident identifiers: 94 and 97.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 40 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident had moisture associated skin damage. This finding was cited at a harm level for resident 6. In addition, another resident sat in a soiled brief for an hour and toileting services were not provided to a resident for 3 hours. Resident Identifiers: 6, 17, and 28. Findings Included: HARM 1. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services. Specifically, two residents complained of uncontrolled pain and the pain medication follow up was documented as ineffective pain control, and the physician was not notified in a timely manner. A resident was also observed to vocalize pain during a wound treatment and was not provided pain medication prior to the treatment as was care planned, this will be sited at a harm level. Resident identifiers: 29 and 90. Finding Included: HARM 1. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with suicidal ideation, suicidal attempt, and homicidal ideation was assessed as requiring mental health services and those services were not provided. The deficient practice identified was cited at a harm Level. Resident identifier: 29.

Inspectors wroteBased on record review and interview, the facility did not promptly act upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. In addition, the facility was not able to demonstrate their response and rationale for resident concerns. Specifically, recurring concerns were voiced by the resident council over the period of approximately 14 months with no follow up to or resolution of the concerns.

Inspectors wroteBased on observation, interview, and record review the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility did not have a full time maintenance worker, resident areas were dirty, there was a lack of hot water in resident bathrooms and communal shower room, a resident bathroom door was in disrepair, a resident had missing items which had not been replaced and a column from the gazebo area outside had a loose metal base which caused a resident to fall resulting in a laceration. Resident identifiers: 4, 21, 26, 30, 31, 33, and 34. Findings Include: MAINTENANCE AND HOUSEKEEPING 1. On 2/7/24 at 9:32 AM, an interview was conducted with resident 4. Resident 4 stated that the dining room tables and table linens were filthy and the dining room usually had a bad odor. [...]

Inspectors wroteBased on interview and record review it was determined, for 4 out of 40 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident threw a can of food at another resident and struck them in the leg. Additionally, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident cut another resident with a razor. In addition, multiple areas of neglect were identfied during the survey. Resident identifiers: 7, 19, 31, and 36.

Inspectors wrote9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. [...]

Inspectors wrote9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], Resident 93 was admitted to the facility. Resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, Resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all allegations of abuse were thoroughly investigated for 3 of 40 sampled residents. Resident identifiers: 16, 33, and 97.

Inspectors wroteBased on interview and record review it was determined, for 3 of 40 sampled residents, that the facility did not incorporate the recommendations from the pre-admission screening and resident review (PASRR) level II determination and the PASRR evaluation report into the resident assessment, care planning, and transitions of care. Specifically, residents had PASRR level II recommendations for mental health services and none were provided. Resident identifiers: 21, 29, and 34.

Inspectors wroteBased on observation, interview and record review, the facility did not provide the appropriate treatment and services to 5 of 40 sampled residents to maintain or improve his or her ability to carry out the activities of daily living. Specifically, multiple residents did not receive showers as desired or scheduled. Resident identifiers: 7, 8, 28, 31, and 34.

Inspectors wroteBased on interview, observation and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents voiced concern about the staffing level both individually and in a group setting, showers were not provided as scheduled, pain medication was not provided timely, incontinence care was not provided timely, and a nurse left the facility to retrieve the keys to the medication cart from the Director of Nursing. Resident identifiers: 1, 4 6, 7, 8, 16, 30, 31, and.

Inspectors wroteBased on interview and record review, the facility used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, three Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified.

Inspectors wrote2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. Resident 31's physician orders revealed the following: a. On 6/21/23, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. The order was discontinued on 1/30/24. b. On 1/30/24, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. c. On 6/21/23, an order was initiated for Escitalopram Oxalate Oral Tablet, give 20 mg by mouth one time a day for depression. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, the temperature in both medication fridges was not within a safe temperature range for medication storage, medications did not have resident information, and medication was available for use past the expiration date. Resident identifiers: 6, 9, 14, 21, 26, 28, 31, and 33.

Inspectors wroteBased on interview and record review, the facility did not provide food that was palatable for 10 of 40 residents. Specifically, residents voiced concerns regarding the food quality in individual interviews, as well as resident council minutes. Resident identifiers: 1, 4, 8, 21, 26, 30, 31, 33, 34 and 36.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, the kitchen was not clean or sanitary and resident meal trays were subject to physical contamination while being served. Findings Included: On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. Hotel pans were stored on visibly soiled white painted shelves. There were metal colanders stored on top of the ice machine. There was a carafe stored upside down on a chipped laminate shelf. The carafe was not dry, and a watery pink liquid was dripping from the carafe into the chips on the laminate shelf. Inside of the shelf was made of particle board. The chips in the laminate indicate that the storage space cannot be fully sanitized. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility infection control tracking and trending was not complete.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not complete.

Inspectors wroteBased on observation and interview, it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility. Findings Included: On 2/13/24 at 10:43 AM, an observation was made of the facility shower room. It was noted that there was a strong odor of both feces and urine in the shower room. On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. A vent on the wall in the dry storage was visibly covered in dust. On 02/14/24 at 1:33 PM, an interview was conducted with the Corporate Maintenance (CM). The CM stated he was temporary and had only been here for 3 days. The CM stated that he got a text from the admin to replace the toilet and that was why he was here. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that nursing assistants received training to ensure ongoing competence, and include dementia management training.

Inspectors wroteBased on observation and interview it was determined, for 2 of 40 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. Specifically, residents were provided cowbells as an alternative to a broken call light and a resident was not provided privacy during a brief change. Resident identifiers: 6 and 26.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident received services in the facility with reasonable accommodation of needs and preferences. Specifically, the resident requested a bed cane be provided for his bed to aid in mobility and the facility did not provide the assistive device. Resident identifier: 7.

Inspectors wroteBased on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not consult with the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status, or when there was a need to alter treatment. Specifically, a resident had uncontrolled pain and the physician was not notified, and a resident's Trulicity was not administered for two consecutive weeks due to unavailability and the physician was not notified. Resident identifiers: 29 and 31.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not ensure that the comprehensive care plan was prepared by the interdisciplinary team that included the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services, the resident or representative, and any other appropriate staff as determined by the resident's need; and that the plan was reviewed and revised by the Interdisciplinary team (IDT) after each assessment including quarterly review assessments. Specifically, nursing staff were not present at the resident's quarterly care conference. Resident identifier: 4.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, the resident desired to return to the community through the New Choice Waiver (NCW) program and the facility did not submit the required paperwork. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 2 of 40 sampled residents, that the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, the facility did not provide or maintain documentation of one on one activities for residents that had care plans for one on one activities and did not provide activities for residents on weekends. Resident Identifiers: 21 and 22.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that residents received proper treatment and care to maintain mobility and good foot health. Specifically, a resident was not provided care with trimming his toenails and appointments to podiatry services were not made. Resident identifier: 7.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 40 sampled residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, a resident was not provided their ordered supplement for 3 days. Resident identifier: 33. Findings Include: Resident 33 was initially admitted to the facility on [DATE] and readmitted with the following diagnoses that included severe protein calorie malnutrition, alcoholic cirrhosis of liver without ascites, dementia, opioid dependence, esophageal obstruction, gastrointestinal hemorrhage, generalized anxiety disorder, and alcohol dependence. Resident 33's medical record was reviewed on 2/6/24 through 2/22/24. On 2/6/24, resident 33's documented weight was 86 pounds. [...]

Inspectors wroteBased on observation and interview, it was determined for 1 of 40 sampled residents that the facility did not ensure intravenous (IV) therapy was administered consistent with professional standards of practice as well as implement prevention of infection at the IV site to the extent possible. Specifically, a resident was observed to have IV fluid lying on a flat surface while being administered and no alcohol caps were observed on the IV hub. Resident Identifier: 26 Findings Include: Resident 26 was admitted to the facility on [DATE] with the following diagnoses of osteomyelitis of right ankle and foot, generalized muscle weakness, polyneuropathy, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis, and necrotizing fasciitis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 40 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the the resident's goals and preferences. Specifically, the facility did not have physician's orders in place for a resident's oxygen tubing to be changed or documentation that the resident's oxygen tubing had been changed. Resident identifier: 7.

Inspectors wroteBased on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not submit and follow-up on the application process for the New Choice Waiver (NCW) program that provided support services to enable residents to reside in their own home or other community-based settings. Resident identifiers: 4 and 31.

Inspectors wroteBased on interview and record review it was determined for 1 of 40 sampled residents, the facility did not ensure that each resident was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, a resident's blood pressure was not monitored before being administered pain medication as ordered by the physician. Resident Identifier: 16. Findings Included: [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that residents were free from any significant medication errors. Specifically, a resident's Trulicity medication was omitted for two consecutive weeks due to unavailability from the pharmacy. Resident identifier: 31.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, a resident had orders for labs that were not obtained by the facility. Resident identifier: 31.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the facility dishwasher spilled water onto the floor whenever a dishwashing cycle was run.

Inspectors wroteBased on observation and interviews it was determined, for 2 of 40 sampled residents, that the facility did not adequately equip each resident with a communication system that was relaying calls directly to staff or a centralized work area. Specifically, residents call lights were not functioning properly. Resident identifiers: 26 and 30. Findings Included: On 2/8/24 at 1:52 PM, an observation was made of the maintenance log located next to the nurse's station. The maintenance log dated 2/4/24 documented there was a repair/safety concern that needed to be fixed for room [ROOM NUMBER] b and c. It documented the following issue, Light needs fixed please. Call light stays on. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26 who resided in room [ROOM NUMBER] B. Resident 26 stated the call light had not been working for the last two days. [...]

Inspectors wroteBased on record review and interview it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, multiple entity reports of abuse allegations were not submitted to the State Survey Agency in a timely manner. Resident identifiers: 3, 9, 12, 14, 22, 24, 25, and 27.

Inspectors wroteBased on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated. Resident identifiers: 3, 12, 22, 25, 27, and 82.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 23 sample residents were free from abuse. Specifically, a resident was determined to have been verbally abused by a staff member. In addition, a resident hit another resident on the head. It should be noted that based on the victims' reactions in both of these cases, the deficiency was not cited at a harm level. Resident identifiers: 3, 12, and 22.

Inspectors wroteBased on interview and record review it was determined that the facility did not have an effective system to record the disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.