Meadow Park Rehabilitation and Health Center LLC

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Abbreviated Survey (Complaint #2714675), the facility failed to ensure sufficient nursing staff was consistently provided to meet each residents' needs. Specifically, the facility's staffing levels were repeatedly below facility assessed minimum levels and the Payroll Based Journal Staffing Data Report from 07/2025 through 09/2025 triggered excessively low weekend staffing.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences. This was evident for one (1) (Resident #10) of one (1) resident reviewed for Activities out of 38 total sampled residents. Specifically, Resident #10 was observed during multiple observations not engaged in any activity in accordance with their preferences.

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (2616957), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on 09/13/2025, during morning care, Resident #1 sustained a fall when Certified Nursing Aide #1 provided care without another staff as per the plan of care. Resident #1 was transferred to the hospital and diagnosed with a nasal fracture. The finding is:The facility policy and procedure titled 'Accident/Incident' revised 12/04/2023 documented the facility will ensure the resident's environment remains as free of accident hazards as is possible. The policy also documented all accidents will be investigated, documented and reported to the New York State Department of Health as appropriate. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00336488), the facility did not ensure the resident's right to be free from abuse and neglect. This was evident for one (1) out of four (4) residents (Resident #1). Specifically, on 03/19/2024 at 9:45 PM Licensed Practical Nurse #1 responded to a loud noise coming from Resident #1 and Resident #2's room. When Licensed Practical Nurse #1 approached the room they observed Resident #2 standing in the doorway holding a wheelchair leg rest in their hand and Resident #1, who was Resident #2's roommate, sitting on the floor in the room. Resident #1 had a laceration to the left side of their forehead and was transferred to the hospital on [DATE]. The hospital Discharge summary dated [DATE] documented left facial and periorbital soft tissue swelling/hematoma. Laceration repaired. [...]

Inspectors wroteBased on record review, and interviews conducted during an Abbreviated Survey (NY00336488), the facility did not ensure that the results of all investigations pertaining to alleged violations involving abuse, neglect, exploitation or mistreatment, were reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident for one out of four residents (Resident #1) sampled for abuse. Specifically, on 03/19/2024 at approximately 9:45 PM Licensed Practical Nurse #1 responded to a loud verbal disagreement into Resident #1 and Resident #2's room. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336488), the facility did not ensure that all incidents were thoroughly investigated. This was evident for (1) out of (4) residents (Resident #1). Specifically, on 03/19/2024 at 9:45 PM Licensed Practical Nurse #1 responded to a loud noise that was coming from Resident #1 and Resident #2's room. When Licensed Practical Nurse #1 approached the room, they observed Resident #2 standing in the doorway to their room holding a wheelchair leg rest in their hand and Resident #2's roommate, Resident #1, sitting on the floor in their room. Registered Nurse Supervisor #5 assessed Resident #1 who had a laceration to the left side of their forehead. Resident #1 was transferred to the hospital for an evaluation on 03/19/2024. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00355163), the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and their needs, and that each resident and resident representative, if applicable, is involved in the developing the care plan and making decisions about their care. This was evident for one (1) out of four (4) residents (Resident #4). Specifically, on 08/06/2024 at 10:25 PM Resident #4 was observed on the floor next to their bed. The Physical Therapist evaluated the resident on 08/07/2024, as ordered by the physician, and recommended a floor bed. [...]

Inspectors wroteBased on interviews and record review conducted during Recertification and Complaint investigations (NY00332356), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported to the State Survey Agency. Specifically, the facility did not report suspected abuse that resulted in a resident sustained a 4-centimeter hematoma to right side of their forehead. This was evident for 2 of 2 residents reviewed for Abuse out of a sample of 30 residents. (Resident # 12 and Resident #68).

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification/Complaint Survey from 3/26/24 to 4/2/24, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no comprehensive care plan developed and implemented for resident's use of anticoagulant therapy. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of 30 sampled residents (Resident #59).

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure that drugs and biologicals were safe and secure to protect from unauthorized access. Specifically, 1) antibiotic solutions and intravenous fluids were located in unlocked cabinets in the nurse's station on the 3rd floor where authorized licensed staff and unauthorized staff were noted entering the nurses station area, and 2) medications were noted to be left out on the medication cart unsecured. This was evident for the Medication Storage Task on Unit 2 and Unit 3.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident for 1 of 3 dining rooms (2nd Floor). Specifically, Certified Nursing Assistant #6 was observed assisting multiple residents with hand hygiene with bare hands without performing hand hygiene in between residents and was also observed touching the inside of paper and plastic cups while preparing beverages for residents at the lunch meal on the 2nd floor. This was evident for 1 of 3 dining rooms during the Dining Task.