Meadowbrook Care Center

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for 2 (Resident #1 and #2) of 4 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 grabbed Resident #2's right arm during an altercation on 03/25/2026 at 12 p.m. in the doorway of Resident #1's room, where the residents' wheelchairs had become entangled. This failure could place residents at risk for emotional distress, fear and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accident hazards for one of ten residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A used a transfer aid when she transferred Resident #1 from her bed to wheelchair, which resulted in her falling and obtaining a fracture to her left hip. On 01/30/2026 at 2:00 pm, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/31/2026, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for serious injury, harm, impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for eight (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of twenty-nine residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's Comprehensive MDS Assessments accurately reflected the residents were using mechanical lifts. This failure could place residents at risk for not receiving care and services needed to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for six (Residents #1, #4, #5, #6, #7, and #8) of twenty-nine residents reviewed for care plans. The facility failed to ensure Residents #1, #4, #5, #6, #7, and #8 were care planned for the transfer mode used on 01/29/2026. This failure could place residents at risk of not receiving the necessary care needed during transfer.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for seven (Resident #1, #2, #16, #20, #22, #24, and #25) of seventeen residents reviewed for privacy and confidentiality.1. The facility failed to ensure a list of hospice residents (Residents #2, #22, #24) was not left on top of the CNA's cubicle unattended on 07/01/2025.2. The facility failed to ensure MA B did not leave Resident #16's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for potassium on top of the medication cart unattended on 07/01/2025.3. The facility failed to ensure RN A did not leave Resident #25's order for wound care on top of treatment cart unattended on 07/02/2025.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 15 resident rooms on the [NAME] Hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8) reviewed for environment. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #51) of ten residents reviewed for pharmaceutical services. 1. The facility failed to ensure MA B did not leave Resident #51's medications inside the resident's room for the resident to take unsupervised on 07/01/2025 2. The facility failed to ensure MA C did not put her personal beverage on the medication cart while passing medications on 07/02/2025. 3. The facility failed to ensure that there was no expired nasal sprays inside the medication room on 07/02/2025. These failures could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to place a lid on top of the trashcan to avoid air borne contaminants. The facility failed to ensure prepared food in the refrigerator was labeled and dated when stored. The facility failed to ensure foods located in the freezer were sealed from air-borne contaminants. The facility failed to ensure all foods stored in the freezer and refrigerator were labeled and dated when stored. The facility failed to dispose of expired foods in the dry storage area. The facility failed to ensure kitchen equipment was cleaned. The facility failed to ensure the kitchen and dining area was cleaned and sanitized. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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 life for two (Resident #1 and Resident #7) of fifteen residents reviewed for dignity.1. The facility failed to ensure CNA F properly covered Resident #1 while repositioning the resident in the hallway on 07/02/2025.2. The facility failed to ensure CNA D did not stand in front of Resident #7 while assisting the resident to eat during lunchtime on 07/01/2025. These failures could place the residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #22) reviewed for accident prevention. The facility failed to ensure Resident #22's fall mat was place alongside his bed for fall prevention. This failure could prevent the resident from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #6's t-tube (used to receive medications by breathing in mist through the mouth) for breathing treatment was properly stored when not in use on 07/01/2025 and that there was a sign outside the resident's room to indicate that oxygen was in use on 07/01/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for two (Resident #2 and Resident #25) of sixteen residents reviewed for medication storage. 1. The facility failed to ensure #Resident #2's anti-fungal powder was not left on top of the resident's side table on 07/01/2025. 2. The facility failed to ensure Resident #25 did not have a bottle of eyedrops on her overbed table on 07/01/2025. These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects.

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #50) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA E changed her gloves and performed hand hygiene during Resident #50's incontinent care on 07/01/2025.2. The facility failed to ensure that CNA F changed his gloves and performed hand hygiene during Resident #1's incontinent care on 07/02/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they assisted residents in obtaining routine dental care for 1 of 8 residents (Resident #3) reviewed for dental services. The facility failed to refer Resident #3 for dental services. This failure could put residents needing dental services at risk of oral complications or weight loss, resulting in a decreased quality of life.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #17) of eight residents observed for infection control. The facility failed to ensure that CNA A and CNA B did not place the used bed padding on top of Resident #17's open, clean, and new brief. This failure could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food containers and cooking products in the kitchen and in the dry food pantry were closed, covered, or sealed properly. 2. The facility failed to ensure the facility's kitchen and dry food pantry were clean of dirt and debris. 3. The facility failed to ensure that staff covered their head and beard while conducting dietary duties. 4. The facility failed to ensure that the dishwasher worked properly. 5. The facility failed to cover the clean bowls and stored in the bowl rack. These failures could place residents at risk for cross contamination and other bacteria illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance that is palatable, attractive, and at a safe and appetizing temperature for 6 of 6 Residents (Resident #20, #6, #31, #17, #14, #35) reviewed for food and nutrition services. The facility failed to ensure the pureed chicken was prepared in a way to preserve vitamins and taste by not following required measuring when adding thickener to the pureed chicken. This failure could place residents at risk of nutrition and hydration and negatively impact the recovery from, illness or injury.