Meadowbrook Care Center

Inspectors wroteBased on observations, interviews and record review during survey, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) that meet the needs of each resident. This was identified for 12 (Resident #31, Resident #33, Resident #43, Resident #48, Resident #53, Resident #97, Resident #175, Resident #229, Resident #259, Resident #271, Resident #276, Resident #283) of 40 residents on Unit 3A during the Medication Storage task. Specifically, during the medication storage task observation on 05/20/2026 12 of 40 resdient's on unit 3A did not receive their medications on time, one hour before or after medication order time, as per the physician's orders. This is a repeat deficiency. The findings inlcude but were not limited to: [...]

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure it provided an infection control program designed to help prevent the development and transmission of communicable diseases for two (Resident #140 and #125) of five residents observed during medication administration and for one (1) (Resident #193) of ten (10) residents reviewed for infection control task. Specifically, during the medication administration observation on 05/14/2026, 1) Licensed Practical Nurse #3 wore gloves to fill an irrigation kit bottle with tap water from the bathroom sink and then went to the bedside of Resident #140 to flush the gastrostomy tube without changing gloves or sanitizing hands; 2) Licensed Practical Nurse #4 used bare hands to break a potassium chloride table in half at the request of Resident #125 because the table was too large to swallow; [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for two (2) (Resident #5 and Resident #13) of four (4) residents reviewed for accidents. Specifically, 1) Resident #5 was observed with an unlabeled bottle of Tums (antacid medication to relieve heartburn and acid indigestion) on their overbed table. Resident #5 did not have a physician's order for the use of Tums or a self-administration assessment. There was no Nursing staff within the vicinity of Resident #5's room. 2) Resident #13 was observed with a labeled clotrimazole cream (an antifungal cream) one (1) percent on their overbed table. There were no nursing staff within the vicinity of Resident #13. [...]

Inspectors wroteBased on record review and interviews during survey, the facility failed to ensure that for each resident, radiological diagnostic tests were obtained in a timely fashion. This was identified for one (1) (Resident #293) of three (3) residents reviewed for hospitalization. Specifically, on 03/09/2026 Resident #293 had a physician order for a chest x-ray due to fever. There was no documented evidence that the chest x-ray was ever completed. On 03/11/2026 the resident was transferred to the hospital and was admitted with a diagnosis of pneumonia.(Complaint #2967962)

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that an account of all controlled drugs was accurately maintained. This was identified on one (Unit 1B) of eight units. Specifically, during the medication storage task observation on Unit 1B, the Oxycodone (a narcotic pain medication) count documented in the controlled substance record did not match the amount of Oxycodone tablets present in the blister pack for Resident #407. The finding is: The facility's policy titled Management of Controlled Medications, revised 5/24/2024, documented all controlled drugs will be subject to special receipt, handling, storage, disposal, and record keeping. Controlled drug records will be maintained in such a manner as to ensure accountability, security, and ease of tracking. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that the facility assessment accurately included what resources were necessary to care for its residents competently during day-to-day operations. Specifically, the Facility Assessment incorrectly assessed the need for an excessive number of Certified Nurse Aides during the day shift (7:00 AM-3:00 PM). The finding is: The Facility assessment dated [DATE] documented the facility was assessed to have 57 Certified Nurse Aides (39 facility staff and 18 agency staff) for the day shift (7:00 AM - 3:00 PM). The Administrator was interviewed on 7/29/2024 at 1:57 PM and stated they reviewed and approved the Facility Assessment on 5/1/2024. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/23/2024 and completed on 7/29/2024 the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #452) of seven residents reviewed for Respiratory Care. Specifically, Resident #452 was observed receiving oxygen on 7/23/2024, 7/24/2024, and 7/25/2024 without a physician's order. The finding is: The facility policy titled, Oxygen Therapy and Monitoring dated 9/17/2019 and revised on 9/11/2023 documented that residents requiring oxygen will have oxygen ordered either as needed or continuously by the physician and/or physician extender. [...]

Inspectors wroteBased on record review and interviews during the Recertification survey initiated on 7/23/2024 and completed on 7/29/2024, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for three (Residents #201, #205, and #63) of three residents reviewed for the Resident Assessment Facility Task. Specifically, Resident #201's Discharge Minimum Data Set (MDS) assessment was not electronically submitted to the Centers for Medicare and Medicaid Services (CMS) until 132 days after completion of the assessment; Resident #205's Quarterly Minimum Data Set (MDS) assessment was not electronically submitted to the Centers for Medicare and Medicaid Services (CMS) until 16 days after completion of the assessment; [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated survey (Complaint # NY 00274435 and NY 00283476) initiated on 11/7/22 and completed on 11/14/2022 the facility did not ensure that residents who have an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. This was identified for one (Resident # 295) of two residents reviewed for Urinary Catheter. Specifically, Resident #295 was admitted to the facility with a chronic long-term use of a Foley catheter and treatments to flush the catheter. The Foley catheter (F/C) care was not documented as completed every shift as ordered by the Physician. The finding is: Resident #295 was admitted to the facility on [DATE] with the diagnosis of Bladder Cancer. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022, 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. This was identified for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61 had an unwitnessed fall on 9/5/2022 and was found sitting on the floor at 4 AM in their (Resident #61) room near the bathroom. The resident sustained a fractured left hip as a result of the fall. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022 the facility did not ensure that accident were thoroughly investigated for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61 who required assistance with toileting, had an unwitnessed fall on 9/5/2022 and was found sitting on the floor at 4 AM in their (Resident #61) room near the bathroom. The Accident and Incident (A/I) report did not identify that the assigned Certified Nursing Assistant (CNA) #1 did not provide toileting assistance to Resident #61 as indicated in the resident's plan of care. Additionally, the A/I report sections were left blank regarding when the resident was last toileted; if the resident was wearing appropriate footwear; and the report did not identify the resident's ambulation and transfer status. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/7/2022 and completed on 11/14/2022, the facility did not implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #61) of three residents reviewed for Accidents. Specifically, Resident #61, was occasionally incontinent of bladder and required assistance with toileting every 2-4 hours as indicated on the Comprehensive Care Plans (CCP). There was no documented evidence that the resident was toileted every 2-4 hours as indicated on the CCP. [...]