Meadowbrook Care Center

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness. This had the potential to affect all of the residents residing in the facility with the exception of for eight facility-identified (Residents#1, #8, #15, #20, #43, #67, #91, and #124) with orders for nothing by mouth. The facility census was 107 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to provide residents with a dignified dining experience. This affected 13 (Residents #39, #79, #55, #20, #45, #31, #49, #17, #42, #32, #48, #71, and #102) with the potential to affect all of the residents except eight residents with orders for nothing by mouth (NPO). The facility census was 107 residents.

Inspectors wroteBased on review of the facility menu, review of the dietary spreadsheet, observation, staff interview, and policy review, the facility failed to ensure staff followed the menu for residents with orders for a pureed diet. This affected ten facility-identified (Residents (#9, #11, #17, #20, #26, #45, #60, #66, #112 and #122) with order for a pureed diet. The facility census was 107 residents.

Inspectors wroteBased on review of the facility diet listing, review of the facility menu, review of the facility spreadsheet, observation, staff interview, and policy review, the facility failed to ensure residents with an order altered textured diets were served foods in a form that was safe and appropriate. This affected 35 facility-identified with orders for diets with altered textures. The facility census was 107 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure residents received appropriate incontinence care. This affected one (Resident #97) of three residents reviewed for incontinence care. The facility census was 107 residents.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #116) of three closed resident records sampled. The facility census was 107 residents.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to provide a sanitary environment for residents. This affected one (Resident #97) of five residents reviewed for physical environment. The facility census was 107 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility to properly store, label and date food, failed to monitor refrigerator temperatures, failed to dry dishes in sanitary manner, failed to ensure staff prepared food in a clean and sanitary manner, and failed to ensure staff wore beard restraints during food preparation. This had the potential to affect all of the residents residing in the facility. The facility census was 89 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to the washers were maintained in a clean manner and free of leaks. This had the potential to affect all of the residents residing at the facility. The facility census was 89 residents.

Inspectors wroteBased on record review, resident interview, staff interview, and review of the facility policy, the facility failed to document and follow up on resident concerns brought up in the Resident Council meetings. This affected 10 (Residents #12, #15, #33, #36, #40, #46, #51, #63, #72, #78) of 10 residents who regularly attended the Resident Council meetings. The facility census was 89 residents.

Inspectors wrote2. Observation on 05/07/25 at 10:11 A.M. of the C Hall shower room with LPN #146 revealed there was an area measuring approximately two inches by three inches of brown skid marks of an unidentified substance on the wall by the toilet. Further observation revealed the walls surrounding the entire shower area contained a layer of a brown unidentifiable material where the wall met the floor, measuring approximately two inches up the wall. Interview on 05/07/25 with LPN #146 confirmed the brown skid marks on the wall by the toilet and the brown substance on the walls surrounding the shower and all of the C Hall residents had access to the shower room. [...]

Inspectors wrote4. Review of the medical record for Resident #10 revealed and admission date of 12/15/22 with diagnoses including diabetes, schizoaffective disorder and chronic kidney disease. Resident #10 was hospitalized from [DATE] to 12/13/24 and returned to the facility. Review of the MDS assessment for Resident #10 dated 04/01/25 revealed the resident had severely impaired cognition and was dependent on staff for ADLs. Interview on 05/06/25 at 2:25 P.M. with Regional Operations Manager (ROM) #501 confirmed the facility failed to provide a bed hold notice to Resident #10's representative for the resident's hospitalization from 11/14/24 to 12/13/24. 3. Review of the medical record for Resident #06 revealed an admission date of 12/30/21 with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. [...]

Inspectors wroteBased on review of medical records, observation, staff interview and review of the facility policy, the facility failed to serve food portions as planned by the Registered Dietitian (RD). This affected six (Residents #9, #13, #21, #30, #38, #65) of six residents with orders for a pureed diet. The facility census was 89 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident physicians/medical providers of significant weight loss. This affected one (Resident #45) of eight residents reviewed for weight changes. The facility census was 89 residents.

Inspectors wrote3. Review of the medical record for Resident #43 revealed an admission date of 8/11/24 with diagnoses including diabetes mellitus, bipolar disorder, and Alzheimer's Disease. Review of the MDS assessment for Resident #43 dated 3/12/25 revealed the resident had severely impaired cognition and received insulin. Observation on 05/05/25 at 11:27 A.M. revealed Resident #43 was seated in the dining room with multiple residents who were waiting for lunch to be served. Registered Nurse (RN) #152 approached Resident #43 and told her she was going to check her blood sugar. RN #152 did not obtain consent from the resident. RN #152 then cleansed Resident #43's finger and pierced it with a lancet to obtain a blood sample to perform a blood sugar check. Interview on 05/05/25 at 11:35 A.M. [...]

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to ensure hypnotic medications were used with adequate indications for administration and with adequate monitoring. This affected one (Resident #75) of five residents reviewed for unnecessary medications. The facility census was 89 residents.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure the accuracy of resident Minimum Data Set (MDS) assessments regarding resident dental status and range of motion and mobility. This affected three (Residents #19, #75 and #80) of 21 residents reviewed for MDS accuracy. The facility census was 89 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) was completed within 30 days of being admitted to the facility with a hospital exemption. This affected one (Resident #19) of four residents reviewed for PASARR completion. The facility census was 89 residents.

Inspectors wroteBased on medical record review and staff interview facility failed to revise Preadmission Screening and Resident Review (PASARR) assessments after a change in resident condition. This affected one (Resident #58) of four residents reviewed for PASARR completion. The facility census was 89 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to develop comprehensive resident care plans. This affected two (Residents #19 and #75) of 21 residents reviewed for care planning. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to conduct quarterly care conferences. This affected three (Residents #10, #24, and #81) of four residents reviewed for care planning. The facility census was 89 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to reassess resident nutritional status following hospitalization. This affected one (Resident #81) of two residents reviewed for readmission. The facility census was 89 residents.

Inspectors wrote2. Review of the medical record for Resident #19 revealed an admission date of 03/22/25 with diagnoses including osteoarthritis, benign prostatic hyperplasia glaucoma, chronic kidney disease, and intellectual disabilities. Review of the MDS assessment for Resident #19 dated 03/26/25 revealed the resident was moderately cognitively impaired, required supervision with ADLS, and was admitted with two stage III pressure ulcers and one unstageable pressure ulcer. Review of the care plan for Resident #19 dated 04/01/25 revealed the resident was at risk for the development of pressure ulcers related to the disease process, decreased mobility and moisture exposure. Interventions included staff to administer treatments as ordered and monitor for the effectiveness and to follow facility protocols for the prevention of and treatment of skin breakdown. [...]

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff administered resident tube feedings in a sanitary manner. This affected one (Resident #75) of one residents reviewed for tube feeding. The facility census was 89 residents.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a medication error report, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for medication errors. The facility census was 89 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and consulting pharmacist interview, the facility failed to ensure insulin pens were properly labeled and stored. This affected three (Residents #65, #39 and #34) of 21 facility- identified residents who received insulin. The facility census was 89 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide specified foods for residents with physician's orders to be on a renal diet. This affected one (Resident #81) of two residents reviewed for specialized diets. The facility total census was 89 residents.

Inspectors wrote2. Review of the medical record for Resident #18 revealed an admission date of 02/22/25 with diagnoses including rhabdomyolysis,COPD, and chronic respiratory failure. Review of the MDS assessment for Resident #18 dated 03/06/25 revealed the resident had severe cognitive impairment and required staff assistance with ADLs. Observation on 05/06/25 at 10:59 A.M. revealed Certified Nursing Assistant (CNA) #882 was wearing gloves and entered Resident #18's room Observation on 05/06/25 at 11:00 A.M revealed CNA #882 exited Resident #18's room still wearing gloves and assisted the resident to the dining room. Interview on 05/06/25 at 11:02 AM with CNA #882 confirmed she entered Resident #18's room and she was wearing gloves. CNA #882 confirmed she assisted Resident #18 to the dining room and she was still wearing the same gloves that she was wearing upon entry to the resident's room. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a residents and/or resident representative received education regarding the benefits and potential side effects of the influenza immunization. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the Coronavirus (COVID-19) vaccine. This affected one (Resident #10) of five residents reviewed for immunizations. The facility census was 89.

Inspectors wroteBased on record review, staff interviews, and review of facility policy, the facility failed to ensure their policy regarding abuse was implemented when facility staff found a male and female resident in a bed together. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on record review, staff interviews, review of facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to timely report an an alleged incident of abuse. This affected one (#4) of the two residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing high-contact care to residents in Enhance Barrier Precautions (EBP). This had the potential to affect all residents. The facility census was 93.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure residents had access to call lights. This affected one (Resident #46) of five residents sampled for call lights. The facility census was 93.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure residents received wound care as ordered. This affected one (Resident #41) of one resident of two reviewed for wounds. The facility census was 93.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents received pain medications timely. This affected one (Resident #75) of six residents sampled for medication administration. The facility census was 93.

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure residents received medications as ordered and to maintain a medication error rate of less than 5%. This affected two (Residents #41 and #51) of six residents sampled for medication administration. The facility census was 93.

Inspectors wroteBased on medical record review, observation, and staff and resident interviews, the facility failed to ensure a pressure ulcer dressing change was completed per physician orders. This affected one (#93) of three residents reviewed for pressure ulcers. The facility identified four pressure ulcers in the facility. The facility census was 99.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure proper colostomy care was provided. This affected one (#77) of three residents reviewed for colostomy care. The facility identified three residents with colostomies. The facility census was 99.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure the attending physician completed resident visits every 60 days. This affected two (#2 and #3) of three residents reviewed for physician visits. The facility census was 99.

Inspectors wroteBased on employee file review and staff interviews, the facility failed to ensure they employed a qualified dietary manager. This had the potential to affect all 96 residents who received food from the kitchen. The facility census was 97.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to store food, drink, and meal services items in a safe and sanitary manner. This had the potential to affect all 96 residents who received food from the kitchen. The facility identified one (#1) resident who had orders for nothing by mouth. The facility census was 97. Findings Include: 1. Observation of the kitchen during tour on 11/13/23 from 8:45 A.M. to 9:05 A.M. revealed an unlabeled and undated three gallon pitcher of liquid, a container of sauerkraut dated 11/09/23, and an open container of whole milk with no date in the reach-in refrigerator; an open container of grape jelly with no open date and six bags of rolls with no open or expiration date on the food preparation counter; no thermometer inside the milk cooler; [...]

Inspectors wroteBased on observation, staff interviews, resident interviews, and policy review, the facility failed to ensure residents had a safe, comfortable, and homelike environment. This affected eight (Residents #36, #13, #58, #45, #86, #55, #30, and #78) of eight residents reviewed for environment. Additionally, this affected all residents residing on the Unit B Memory Care Unit (MCU). The census was 97.

Inspectors wroteBased on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications to residents. This affected three (Resident #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the unlicensed company. The facility census was 97.

Inspectors wroteBased on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications. This affected three (Residents #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to provide puree foods per the spreadsheet approved by the dietitian. This had the potential to affect six (Residents #52, #30, #13, #4, #45 and #55) who received puree consistency diets from the kitchen. The facility census was 97.

Inspectors wroteBased on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Residents #47, #78, and #87) of three reviewed for medications administered by IV Company #700. The facility identified 22 Residents (#1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97.

Inspectors wroteBased on review of the facility's infection control log, staff interview, and review of facility policy, the facility failed to have an affective antibiotic stewardship program. This affected five (#2, #23, #41, #61, and #91) of five residents reviewed on the infection log. The census was 97.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure call lights located in resident bathrooms had pull cords and residents would be able to activate if on the floor. This affected four (#29, #31, #89, and #407) of four residents reviewed for call light functionality. The census was 97.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected two (Residents #47 and #44) of two residents reviewed for dignity and respect. The census was 97.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected one resident (Resident #33) of eight residents reviewed for advanced directives. The facility census was 97.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident received regular care conferences. This affected one (Resident#29) of one reviewed for care conferences. The census was 97.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's feet were kept clean. This affected one (Resident #47) of four residents reviewed for activities of daily living assistance. The census was 97.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to provide incontinence care per standards of care. This affected one (Resident #47) of one resident observed for incontinence care. The facility census was 97.

Inspectors wroteBased on medical record review, staff interviews, resident interview, and review of facility policy, the facility failed to complete a urinalysis as ordered. This affected one (Resident #78) of one resident reviewed for laboratory services. The facility census was 97.