Meadowbrook Healthcare

Inspectors wroteBased on observation, interviews, and record review conducted during recertification and abbreviated survey (NY00329299), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for 5 (Residents #76, 104, 119, 139, and 177) of 44 residents reviewed for comprehensive care plans. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions for 4 (Resident #'s 50, 53, 76, and #177) of 44 residents reviewed. Specifically, (a.) for Resident #53, the comprehensive care plan for Clotridoides or Clostridium difficile infection (a bacterium that causes diarrhea and inflammation of the colon) was not updated when the infection had resolved; (b.) for Resident #76, the fall care plan was not revised after the most recent Minimum Data Set Assessment; the comprehensive care plan for behaviors did not include a psychiatric consult or on-going psychiatric services; [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (Case #s NY00326260, NY00329259, NY00334623, and NY340304), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nurse Aides were not met every day on multiple shifts and multiple units, from 10/05/2024 to 10/20/2024. This is evidenced by: The Facility assessment dated [DATE], documented budget and minimum nursing staffing levels needed for each unit during the 7-3 shift (day), 3-11 shift (evening), and 11-7 shift (night), when the resident census was 233: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 3 (Resident #s68, 182 and 199) of 6 residents observed during a medication pass for a total of 34 observations. This resulted in a medication error rate of 38.24%. This is evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified by the physician. Nurses must take every safety precaution when administering medications. The Five Rights are safety rules to be implemented each time a drug is administered: o Right Medication o Right Patient/Resident o Right Time o Right Route o Right Dose. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates, and (b) a medication cart was left unattended and unlocked. This was evident for 3 (Aspen, Subacute, and Orchard Units medication carts) out of 3 medication carts reviewed. This was evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened should be recorded on the container. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 6 of 6 resident unit kitchenettes and main kitchen. Specifically, area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During observations in the main kitchen on 10/20/2024 at 5:45 PM, the rolling toaster appliance had a large amount of buildup and debris on the device. In a follow up observation on 10/22/2024 at 9:34 AM the rolling toaster was not cleaned and still had a large buildup of debris on the device. During observations on the Orchards 1st Floor Unit on 10/22/2024 at 10:34 AM, the resident kitchenette microwave had food particles along the door and on the interior of the appliance. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infection for all residents and staff in facility reviewed for infection control. Specifically, facility staff did not properly use personal protective equipment on units with COVID. This is evidenced by: The Infectious Disease Outbreak Control policy, revised 07/19/2024, all employees would maintain transmission-based precautions as indicated During an observation on 10/22/2024 at 10:34 AM on the subacute unit, a nurse exited a resident room wearing a cloth gown. The nurse removed the gown in the hallway outside of the resident's room. The resident in the room (room [ROOM NUMBER]) was on transmission-based precautions for COVID. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure the resident representative and the physician was notified when there was a change in condition that required a change in the residents' plan of care, medication, or treatment regimen for 3 (Resident #s 7, 58, and 198) of 3 residents reviewed for resident notification issues. Specifically, (a.) for Resident #7, provider was not notified when resident had a fall with a fracture on 8/20/2024 until the next day. For (b.) Resident #58, representative was not notified of a fall on 8/29/2024 and the need for x-rays for 9 hours; (c.), for Resident #198, representative was not notified when Haldol Lactate Solution 5 MG/ML, give 0.5 mg intramuscularly was ordered and given 4 times on 6/26/2024, 7/12/2024, 7/28/2024 (1 mg), and 7/29/2024. This was evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure the resident had a right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 (Resident #198) of 2 residents reviewed for restraints. Specifically, Resident #198 had a chair alarm (a pad placed on a chair) hooked to a sensor box that alarmed if a wheelchair resident attempted to stand, and had a seat belt around their lap that the resident was not able to remove when asked and that prohibited the resident from rising independently. This is evidenced by: The policy titled Restraints, dated 01/2020, documented that the facility would consider physical restraint after all other interventions were exhausted; [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 residents (Resident #104 and 119) of 2 residents reviewed. Specifically, Residents #104 and 119 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure titled Activities Department, undated, documented its policy was to provide meaningful activities to residents with various cognitive, physical, and social abilities on a regular basis to enhance their quality of life. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent further pressure ulcer for 1 (Resident #50) of 44 residents reviewed. Specifically, for Resident #50, the facility did not (1.) complete an accurate assessments and documentation of an unstageable pressure ulcer on the right great toe identified on 9/23/2024 and a wound on the second toe on the left foot identified on 10/14/2024: (2.) physician ordered treatments for the wounds were not administered as ordered: (3.) the resident's care plan did not include measurable objectives and timeframes to promote healing of the wounds. This is evidence by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 2 (Resident #'s 9 and 122) of 5 residents reviewed for oxygen administration. Specifically, (a) Resident #9, there was no physician's order for Resident #9's oxygen, and (b) for Resident #122 oxygen delivery was not provided by unlicensed personnel. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Administration, dated 02/2020, documented that a physician's order was required for oxygen use and that oxygen would be initiated per the?Medical Directors order or by a?nurse in an acute situation. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services, received such services consistent with professional standards of practice for 1 resident (Resident #150) of 1 resident reviewed for Dialysis. Specifically, Resident #150 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments. This is evidenced by: The facility's Policy and Procedure titled Hemodialysis, reviewed 4/2020, documented: Patients/residents requiring hemodialysis therapy would be transported to the local Renal Center for hemodialysis therapy. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey and abbreviated survey (NY00326260), the facility did not ensure procedures that assured the accurate acquiring, receiving, dispensing, reconciliation, and storage of medications. Specifically, the facility did not ensure that narcotic medications received at the facility were properly destroyed. This is evidenced by: On October 13, 2023, Director of Nursing #1 sent a notification to the New York State Department of Health Bureau of Narcotics advising them of the destruction of controlled substances. A follow-up notification from the manager of the Bureau of Narcotics Enforcement on 10/17/2024 advising the facility that their destruction notification was denied as they did not submit a narcotics license renewal. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for nine (Resident #'s 15, 110, 132, 165, 177, 189, 190, 220, and 246) of 16 residents reviewed. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure that a resident group agreed to the 14 1/2 hour or more time span between the facility's scheduled times for the evening and breakfast meals. This was evidenced by: Review of listed meal times on 2/26/2019 at 10:17 AM showed that dinner was served between 4:40 PM and 5:00 PM. Breakfast was served between 7:30 AM and 7:45 AM, a lapse of 14 1/2 to 14 5/6 hours between the two meals. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced as follows: Review of the facility's policy on Food Brought to Residents from the Outside on 02/26/19 at 10:00 AM, revealed the policy did not include procedures for families and visitors to be educated on the safe preparation, handling, or storage of foods brought in for residents. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 02/27/2019 12:00 PM, revealed that carbon monoxide (CO) detection was not provided near fuel burning appliances in the main kitchen (stoves). The Director of Engineering stated in an interview on 02/29/2019 at 1:50 PM, that a CO detector was added to the kitchen today, but no CO detectors are monitored by the fire panel, and staff has not received training on how to respond to the CO alarms. 483.70 (b); [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey, the facility did not 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 #15) of one resident's reviewed for isolation precautions. Specifically, for Resident #15, on the Aspen Unit, the facility did not ensure droplet precautions were implemented and maintained to prevent the spread of the Respiratory syncytial virus (RSV) and on the Oakwood Unit the facility did not ensure that infection control standards were maintained during a dressing change. This is evidenced by: Resident #15: The resident was admitted to the facility on [DATE] with diagnoses of heart failure and chronic kidney disease. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for residents on 3 of 7 units. Specifically, for Unit's 1, 2, and 4, the facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room, did not ensure that resident's meals were not interrupted by the need for other resident's to enter or exit the dining room, did not ensure that medications were not administered while residents were eating, and did not ensure that residents' seated at the same table received their meals at the same time. This was evidenced by: Unit 1: [...]

Inspectors wroteBased on interview and record review during the recertification survey, the facility did not ensure 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization received written notice of transfer/discharge and the reasons for the transfer in a language and manner they understand. Specifically, the facility did not ensure that there was documented evidence that written notification of transfer/discharge was provided to the resident and/or the resident's representative(s). This was evidenced by: Review of the policy titled Emergency Transfer dated 7/2018, did not include documentation regarding notice of transfer/discharge to the resident and/or resident's representative. Review of the policy titled Discharge Planning dated 12/2015, did not include documentation for notification of hospital transfer/discharge. [...]

Inspectors wroteBased on interview and record review during the recertification survey, the facility did not ensure written notice was provided to the resident and/or the resident's representative of the bed hold and return policy for 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Review of the policy titled Bed Hold Policy dated 6/2018, documented that each resident be given a notice of this policy upon each leave of absence from the facility. It did not include documentation that it must be given in writing. Review of the facility letter used for Bed hold and for hospital transfer/discharge by the social worker is labeled Bed Hold. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Resident #'s 132 and 228) of 4 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 132 & 228 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 (Resident #177) of 5 residents reviewed for visual impairment. Specifically, the facility did not ensure that Resident #177 was provided assistance locating her glasses and that the resident's plan of care included a plan for vision and devices. This is evidenced by: Resident #177: The resident was admitted to the facility on [DATE], with diagnoses of Cerebrovascular Accident, dementia, and diabetes. The Minimum Data Set (MDS) dated [DATE], documented the resident used corrective lenses and had adequate vision. The resident had the ability to be understood and usually understood others. [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY00233249) the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #13) of 5 residents reviewed. Specifically, for Resident #13, the facility did not ensure medications were not left unsecured and unattended at the resident's bedside. This was evidenced by. The Policy and Procedure (P&P) titled Medication Administration dated 6/13/16, documented the facility shall administer medications in a safe and timely manner in accordance with current standards of nursing practice. Never leave medications unattended or unsecured. Resident #130: The resident was admitted to the facility on [DATE], with the diagnosis of Schizophrenia, depression and hypertension. [...]