Meadowbrook Health & Rehabilitation

Inspectors wroteBased on record review, observation, and interviews with staff, Nurse Practitioner, and the Psychiatric Nurse Practitioner, the facility failed to provide effective supervision for a resident who had cognitive impairment, alcohol induced dementia, and a court appointed Guardian. On 12/2/2024 Resident #120 told the Director of Nursing he was upset because he had been told by a staff member that he was going to be moved to the secured unit. Later that same day Resident #120 stacked patio furniture in the enclosed courtyard and then proceeded to climb onto an awning, then up to the roof of the facility. Resident #120 was observed by staff to be running around on the roof and sitting on the edge of the roof with his legs dangling over the edge of the roof. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of narcotic medication for 2 of 3 residents reviewed for misappropriation of resident property (Resident #22 and #6). On 11/6/2025 the facility discovered Resident #22 had a medication card of 30 Oxycodone (a narcotic pain medication) 5 milligram tablets missing from the medication cart's locked narcotic box and on 11/10/2025 the facility discovered Resident #6 had a medication card of 28 Oxycodone 5 milligram tablets missing from the medication cart's locked narcotic box.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a 5-day investigation report to the State Agency for Resident #22 and Resident #6 for misappropriation of narcotic medication. In addition, the facility failed to report Resident #6's missing narcotics to Adult Protective Services or submit an initial allegation report to the State Agency. The deficient practice occurred for 2 of 3 residents reviewed for abuse, neglect, and misappropriation (Resident #22 and Resident #6).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for residents previously determined to have a Level I status for a PASRR after a new serious mental disorder was identified for 4 of 5 residents reviewed for PASRR (Resident #14, Resident #83, Resident #107 and Resident #9).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired leftover and unopened food items stored for use in 1 of 1 walk-in cooler, 1 of 1 dry goods storage room, and 2 of 2 nourishment rooms (100 and 200 Hall nourishment rooms), and failed to remove dented cans stored for use in the dry goods storage room. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to allow a resident who was assessed as safe to smoke without supervision the choice to smoke at preferred times for 1 of 3 residents reviewed for choices (Resident #50).

Inspectors wroteBased on observation and staff and resident interviews, the facility failed to place survey results in a location readily accessible to residents and visitors and available to review without asking.

Inspectors wroteBased on observations, record reviews, and interviews with the facility staff, rehabilitation (rehab) therapy staff, and Medical Director, the facility failed to identify a reclining Broda wheelchair (a specialized type of seating that allows for tilt-in-space positioning) as a restraint that was reclined in a position that prohibited the resident from rising independently and without medical justification for its use in this manner. This occurred for 1 of 3 residents (Resident #119) reviewed for restraints.

Inspectors wroteBased on record review and staff, Nurse Practitioner, and Guardian interviews, the facility failed to allow 1 of 3 residents reviewed for discharge to return to the facility after transfer to the hospital (Resident #120).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) status for 1 of 5 residents (Resident #15) reviewed for PASRR.

Inspectors wroteBased on staff interviews and record review, the facility failed to submit a request for an evaluation for a level II Preadmission Screening and Resident Review (PASRR) for a resident previously determined to have a Level II PASRR status after a significant change in physical and/or mental status was identified. This occurred for 1 of 5 residents (Resident #15) reviewed for PASRR.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for 1 of 11 newly admitted residents reviewed (Resident #119).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to obtain a provider's diet order for a resident after her admission to the facility. This occurred for 1 of 11 newly admitted residents reviewed (Resident #119).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to maintain a urinary catheter drainage bag off the floor to prevent the risk of infection for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #8).

Inspectors wroteBased on observations, record review, and interviews with staff, the facility failed to enter a physician's order for oxygen delivery for 1 of 1 resident reviewed for respiratory care (Resident #101).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 6 residents (Resident #35 and Resident #105) observed during the medication administration.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 6 of 7 days reviewed (12/11/25, 12/12/15, 12/13/25, 12/14/25, 12/15/25, and 12/17/25).

Inspectors wroteBased on record review, observations, and staff, Resident, Pharmacy Consultant and Nurse Practitioner interviews, the facility failed to administer pain medication as ordered for 1 of 3 residents (Resident #2) reviewed for pain management.

Inspectors wroteBased on record review and staff and Nurse Practitioner interviews, the facility failed to ensure a resident was transported to a scheduled urologist appointment on 1/2/2025 to have their suprapubic indwelling urinary catheter changed. The deficient practice occurred for 1 of 1 resident reviewed for medical related social services (Resident #3).

Inspectors wroteBased on record review and staff, Nurse Practitioner, Pharmacy Consultant, and resident interviews, the facility failed to ensure 1 of 1 resident (Resident #2) had pain medication available that was ordered on admission to the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to repair a sink drain and pipe which resulted in the kitchen having a large amount of water in the floor which had the potential to be hazardous for staff. Also observed in the kitchen were multiple ceiling vents that were dusty and dirty, and four bags of cereal not labeled or stored properly. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations and staff interviews the facility failed to remove loose garbage and debris from around 2 of 2 trash receptacles located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents.

Inspectors wroteBased on record review and staff interviews the facility failed to complete smoking assessment for 2 of 3 residents reviewed or smoking (Resident # 67 and Resident #91).

Inspectors wroteBased on record review, observations and resident, staff, Police Officer, Nurse Practitioner and Medical Doctor interviews, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 3 residents investigated for abuse (Resident #7). Resident #7 reported to the facility that Nurse Aide (NA)#1 had punched her in her right eye. Resident #7 revealed that Nurse Aide #2 was present during this incident and witnessed the allegation. After this incident Resident #7 had a circular reddish, purple bruise below her right eye and reported she felt angry and upset at the time of the incident.

Inspectors wroteBased on staff, Nurse Practitioner (NP) interviews and record review, the facility failed to notify a residents Responsible Party (RP) for refusals of his prescribed insulin. This was for 1 (Resident #1) of 3 residents reviewed for notification.

Inspectors wroteBased on staff interviews and record review, the facility failed to develop a comprehensive care plan in the area of resident's refusal of medications. This was for 1 (Resident #1) of 3 residents reviewed for comprehensive care planning.

Inspectors wroteBased on staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following a complaint investigation dated 9/3/21 for two deficiencies in the area of comprehensive care planning at F656 and notification of changes at F580. Also, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following the recertification survey dated 5/6/22 for one deficiency in the area of notification of changes at F580. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure dietary staff contained facial hair for staff members with beards serving residents food for the preparation of resident's lunch meal trays. The result of the failure to contain facial hair during meal tray preparation and serving had the potential to affect all residents in the facility who would receive a lunch meal tray, and 138 of 139 residents received meal trays.

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in following the complaint investigation of 11/9/2021, the recertification survey of 05/06/22, the complaint investigation of 11/17/2022, and the complaint investigation of 3/2/2023. This was for 4 re-cited deficiencies, E0001, F655, F696, and F812, which were originally cited on 5/6/2022, 1 re-cited deficiency F584 originally cited on 11/9/2021 and 11/17/2022, and 1 re-cited deficiency F677 originally cited on 3/2/2023. The continued failure of the facility during the 4 federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program.

Inspectors wroteBased on observations, record review, staff interviews, the facility failed to maintain a clean safe and homelike environment by the failure to cover fluorescent tube lighting in 1 of 18 rooms (room [ROOM NUMBER]), failed to secure television cable outlet covers and electrical outlet covers in 4 of 33 resident rooms (rooms 107, 320, 326 and 333), failed to maintain window blinds that were in disrepair with missing and bent slats in 2 of 18 rooms (rooms 109 & 116), failed to provide a window blind in 1 of 18 rooms (room [ROOM NUMBER]), failed to maintain intact sheetrock and clean walls for 1 of 18 rooms (room [ROOM NUMBER]) failed to maintain resident cabinetry in 2 of 18 rooms (room [ROOM NUMBER] bed 2 & room [ROOM NUMBER] bed 1), failed to maintain the interior bathroom cabinet where residents' belongings were stored which was rusted and peeling in 1 of 18 rooms (room [ROOM NUMBER]), [...]

Inspectors wroteBased on record review, observation, resident and staff interviews, the facility failed to provide palatable food for 2 of 4 residents (Resident #51 and Resident #107). Resident #51 was upset because he received gravy without sausage, and his oatmeal was served on his meal plate without a bowl and without sugar or butter. Resident #107 received gravy without sausage and could not eat her oatmeal because it was served on her meal plate without a bowl and without sugar or butter.

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse policy in the areas of reporting allegations of abuse to the state regulatory agency within the required timeframe for 1 of 5 abuse allegation reports reviewed for reporting alleged violations. (Resident #128, #52).

Inspectors wroteBased on observations, record review, resident, and staff interview the facility failed to provide nail care for one of 26 residents (Resident # 69) who was dependent on staff for nail care.

Inspectors wroteBased on record review, observations, and staff, resident and Nurse Practitioner interviews the facility failed to manage a resident's pain for 1 of 2 residents (Resident #74) reviewed for pain.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide documentation in the medical record regarding vaccination status, education on the benefits and potential side effects before being offered the COVID vaccination or refusal for 1 of 5 residents (#47) reviewed for infection control.

Inspectors wroteBased on record review and staff interviews the facility failed to initiate a baseline care plan on admission for 1 of 1 resident (Resident #30) reviewed for hospice services.

Inspectors wroteBased on record review and staff interviews, the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and Pneumococcal Immunizations for 3 of 5 residents reviewed for infection control (Resident #138, #53, and #47).