Meadowbrook Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and clean homelike environment, when the bathroom for two residents (Resident 1 and 2) and the bedroom for one resident (Resident 1) was observed with damaged drywall, missing tiles, and areas of walls not painted. This failure resulted in residents not being provided with a homelike environment in the bathroom and bedroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitative services, as ordered by the physician, for one resident (Resident 1), when it did not evaluate and treat Resident 1 for Physical Therapy (PT). This failure had the potential to result in Resident 1's difficulty in attaining and maintaining his highest practicable level of physical, mental, functional, and psycho-social well-being and to prevent and slow further decline in the resident's condition and physical function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the bathroom call light was functioning for two residents who shared the same bathroom (Resident 1 and Resident 2). This failure had the potential to result in accidents or injuries to Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in accordance with professional standards of practice when the kitchen's double preparation (prep) sink was observed unsanitary with multiple dried food particles in both sinks and underneath the first prep sink was a red bucket filled with yellowish gray fluid. These failures had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population for 53 out of 54 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment and ensure adequate supervision was provided to prevent accidents for one of three residents reviewed (Resident 1), who was at risk for falls, self harm, and exhibited impulsive behavior, as indicated in the plan of care and facility policy. These failures resulted in Resident 1 having eight unwitnessed falls between July 2024 and December 2025. On May 13, 2025, Resident 1 sustained a hematoma (severe bruising with swelling) and a skin tear to her forehead. On December 21, 2025, Resident 1 was found on the floor under her roommate's bed, with two red, swollen eyes, which required Resident 1's transfer to the General Acute Care Hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in accordance with professional standards of practice when one large cookie sheet pan had black crusted residue. This failure had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed and/or initiated to address the long term use of the medication potassium chloride (potassium supplement) for one of six residents reviewed (Resident 33) for appropriate medication use. This failure has the potential for Resident 33 to not be monitored for the effectiveness and/or side effects of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were followed for two of two residents reviewed (Residents 7 and 38), when: 1a. For Resident 7, the medication insulin (a medication that regulates the amount of sugar in the blood), was administered outside of the physician ordered parameter; 1b. For Resident 7, the licensed nurses did not contact the physician for blood sugar levels outside of the physician's ordered parameter; 1c. For Resident 7, the medication glucagon (a medication for emergency treatment of very low blood sugar) was administered outside of the physician's ordered parameter; 2a. For Resident 38, the medication insulin was administered outside of the physician ordered parameter; and 2b. For Resident 38, the licensed nurses did not contact the physician for blood sugar levels outside of the physician's ordered parameter. [...]

Inspectors wroteBased on observation, interview, and record review, the failed to ensure, for two of two medication carts inspected for medication storage:1. Discontinued medications for Residents 7, 35, and 5, were not stored in the medication cart readily available for use; and2. Unidentified medication pills that were not in their original containers or packaging were not stored in the medication cart drawer. These failures had the potential risk for the residents to receive medications that were either discontinued or compromised.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Registered Dietician (RD) conducted comprehensive nutritional assessments on-site from August 12, 2025, to September 25, 2025. This failure had the potential for the residents not to receive the correct nutritional comprehensive assessment that could result in receiving suboptimal nutrition services which could lead to decreased nutrition for vulnerable residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of one resident (Resident 10) food brought from home was consistent with the pureed diet (food mashed or blended to a smooth, pudding like consistency) as ordered by the physician. This failure had the potential for Resident 10 to have a choking incident as a result of eating the food brought by the family from home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nebulizer (a small device that converts liquid medication into an inhalable mist) used to administer respiratory treatment was changed after seven days, in accordance with the facility policy and procedure, for one (Resident 12) of one resident reviewed for oxygen use. This failure had the potential to result in bacterial growth that could affect the health of the vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent (%) when three medication errors out of 28 opportunities was observed for one of six residents (Resident 33) observed for medication administration. This failed facility practice resulted in a medication error rate of 10.71 percent (3 errors out of 28 opportunities) and has the potential for Resident 33 to experience the side effects of the medications not given as prescribed by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 33) observed for medication pass, was free from significant medication error when the medications celexocib (pain medication), potassium chloride (potassium supplement) ER (Extended Release), and ferrous sulfate tablet supplement, were not administered with food as ordered by the physicianThis failure had the potential for Resident 33 to experience the side effects of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the diet order was followed according to physician's order for one of 52 residents reviewed (Resident 5), when Resident 5 was observed to receive a pureed diet on September 22, 2025, during lunch. This failure had the potential to compromise Resident 5's nutritional and medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control measures for one of five residents reviewed for infection control (Resident 3) when one staff member was observed providing care for a resident (Resident 3) on Enhanced Barrier Precautions (EBP - measures used to reduce and prevent infections) without wearing recommended Personal Protective Equipment (PPE). This failure had the potential to result in spreading infection to a vulnerable resident population. On September 25, 2025, at 9:04 a.m., Licensed Vocational Nurse (LVN) 3 was observed entering Resident 3's room and handling her feeding tube (a tube inserted in the stomach, used to deliver nutrition for residents who cannot eat). LVN 3 was observed not wearing appropriate PPE (gown) when handling the feeding tube of Resident 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the posted nurse staffing data was complete when the actual hours were not calculated and posted on a daily basis. This failure resulted in complete staffing information not being readily available to residents and the public.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound care treatments were provided to meet the needs of residents when four sampled residents ' (Residents 1, 2, 3, and 4) were not provided wound care treatment in accordance with the physician ' s orders. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 ' s wounds to worsen and could lead to serious complications.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when one of three sampled residents (Resident 1) was transferred to a general acute care hospital. This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage practice was followed in accordance with the professional standards of practice when a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster was found overflowing with trash. In addition, the lid of the dumpster was not completely closed. This failure had the potential to attract pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practice was followed for two of three residents reviewed (Residents 1 and 2) when: 1. For Resident 1, the oxygen (O2) cannula (a flexible tube with two prongs that fit into the nostrils and delivers supplemental O2) was not dated and an undated nebulizer mask (a medical device that fits over the nose and mouth and allows an individual to inhale a mist of medication directly into their lungs) was found on top of Resident 1 ' s nightstand. In addition, the undated nebulizer mask was not stored in a plastic bag and was exposed to the environment; and 2. For Resident 2, the nebulizer mask was not changed since admission. These failures had the potential for Residents 1 and 2 to be exposed to bacterial cross contamination and the development of infection.

Inspectors wroteBased on interview, medical record review, and facility Policy and Procedure (P&P) review, the facility failed to ensure: 1. A system was developed and implemented to accurately track the movement of controlled medications (medications with high potential for abuse or addiction) to prevent and identify loss or potential diversion (illegal distribution or use for purposes not intended by the prescriber) of controlled medications when the facility was unable to account for the missing controlled medications for ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had resulted in controlled medication abuse or diversion. 2. Accurate accountability of controlled medications. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 3 (Residents #11, #18, and #39) of 15 sampled residents and failed to code a resident with an indwelling catheter for 1 (Resident #26) of 15 sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a privacy bag was used for 1 (Resident #26) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed for 2 (Resident #26 and Resident #34) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure upon admission, that orders were obtained for the placement and ongoing care and maintenance of urinary catheters for 2 (Resident #34 and Resident #26) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure physician orders were followed for 1 (Resident #17) of 1 resident reviewed for supplemental oxygen use.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff assessed a resident's condition and monitored for complications before and after dialysis treatments and failed to ensure there was ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 1 (Resident #53) of 1 sampled resident reviewed for dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of imposed charges for services required for residents to achieve their goals and needs safely, when the facility developed and implemented a policy to charge residents, and/or their families when facility staff accompanied the resident to an appointment outside of the facility. This failure had the potential for residents to be charged for covered services and for residents of the facility to avoid necessary appointments.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications was administered for two of the four sample residents (Residents 3 and 4) in accordance with the physician order. This failure has the potential to negatively affect the health status of Residents 3 and 4.

Inspectors wroteBased on observation, interview and record review, the facility failed, for two of three residents reviewed (Residents 1 and 3), to ensure an inventory of the residents ' belongings were completed upon admission. This failure has the potential for the facility to not be able to protect the resident ' s property or personal belongings from loss or theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a resident's medication that was being taken at home prior to admission, after being notified by a family member (FM), for one of three residents reviewed (Resident 1). This failure resulted in Resident 1 not receiving her Seroquel (an antipsychotic medication used to treat mental disorders) from January 3, 2024 to January 5, 2024, which she had been taking at home. In addition, Resident 1 had shown behavior of being non compliant when redirected during episodes of wandering and had episodes of being aggressive to staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's right leg swelling and active medical diagnoses of deep vein thrombosis (DVT - blood clot) on the right leg were assessed and monitored for one of three residents reviewed (Resident 1). This failure resulted in Resident 1's development of increased edema (swelling) on the right leg with blisters after three days of admission without staff knowledge, leading to Resident 1's transfer to the acute hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1) had a physician order to go out on pass (OOP-temporarily leave the facility for a specific time period) when Resident 1 went OOP for more than 24 hours on December 21, 2023. This failure had the potential for Resident 1 to be at risk for harm, accidents, and/or injury.

Inspectors wroteBased on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure services for skin management and prevention of breakdown was implemented for Resident 1 when the facility did not conduct skin check to identify progression and deterioration of pressure ulcer development to Resident 1 ' s heels and sacro-coccyx (area between the oval surface at the apex of the sacrum, and the base of the coccyx) area. The facility failure had resulted to delayed identification and treatment implementation of pressure ulcer development on Resident 1 ' s bilateral heels on August 15, 2023, and breakdown to sacro-coccyx area the day Resident 1 was discharge on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of sexual abuse to the California of Department of Public Health (CDPH - a state department responsible for enforcing some of the laws in the California Health and Safety Codes) for two of three residents reviewed (Residents 1 and 2). This failure had the potential to result in a delay of investigation and reporting of further allegation of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan for one of three residents (Resident 1) was implemented when Resident 1 was not placed in a private room after an allegation of inappropriate sexual behavior. This failure placed Resident 1's new roommate at risk of potential inappropriate sexual behavior conducted by Resident 1.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment that meets professional standards for food service safety and ensure the residents' food was prepared under sanitary conditions, when: 1. Unpasteurized eggs (have not been heat treated to eliminate bacteria), served to two(Residents 2 and 4) of 49 residents on oral diet , were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of Salmonella infection (bacterial disease that affects the intestinal tract. usually caused by eating raw or undercooked meat poultry or eggs and can be life-threatening in older adults where complications can be dangerous). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide on-going skin assessment, monitoring, and provide necessary interventions, for one of four residents' (Resident 30), reviewed for pressure ulcer, when the resident developed pressure injuries (Stage 1 on the right malleolus, Stage 2 on the right buttock, Stage 1 on the left upper buttock, Stage 3 on the left buttock and Stage 1 on the left posterior knee) and non-pressure injuries (open wound with yellowish dark brown discharge on the right foot 3rd, 4th, and 5th toes). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident was free from neglect, when on-going skin assessment, monitoring and necessary interventions were not provided for one of four residents' (Resident 30) pressure (Stage 1 on the right malleolus, Stage 2 on the right buttock, Stage 1 on the left upper buttock, Stage 3 on the left buttock and Stage 1 on the left posterior knee and non-pressure injuries (open wound with yellowish dark brown discharge on the right foot 3rd, 4th, and 5th toes and dry scab on the left anterior lower knee). These failures resulted in a pressure injury (right heel) evolving from a Stage 2 to a Stage 3 pressure injury, while at the facility. In addition, these failures increased the risk for infection which could eventually lead to septicemia (blood poisoning), tissue necrosis, gangrene, and osteomylitis for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the supervisory staff carried out the functions of the food and nutrition service, when the Dietary Service Supervisor (DSS) and the facility Registered Dietitian (RD), did not provide management and oversight to ensure food was stored, prepared, and served according to the facility and industry standards. The RD and the DSS did not maintain oversight of the day-to-day operations of the dietetic service. This failure resulted in multiple deficient practices observed in the dietetic service. These deficiencies placed 49 residents, who were on an oral diet, at risk for serious harm from unsafe and unsanitary food handling practices and inadequate nutrition. (Cross reference F803 and F812).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs of the residents were met when the food portion sizes for seven residents (Residents 4, 38, 40, 45, 46, 153, and 154) on the menu, were not followed. This failure had the potential for 49 of 49 residents on oral diets not to receive the adequate nutrition which can further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility's Administrator and governing body failed to exercise the general policy and operating directions to ensure effective oversight, staff competency, and essential resources were provided in order to sustain the necessary care, services and treatment necessary to maintain the highest level of practicable, physical, mental and psychosocial wellbeing of each resident. This systemic failure resulted in several major deficiencies identified in the course of the facility's Recertification Survey. They are as follows: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) information were provided to 11 of 14 residents reviewed (Residents 4,10, 24, 27, 28, 30, 35, 38, 44, 47, and 149). This failure had the potential for Residents 4, 10, 24, 27, 28, 30, 35, 38, 44, 47, and 149 not to be able to exercise their rights to formulate an Advance Directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and home-like environment for six of seven sampled residents (Residents 2, 4, 28, 29, 30, and 38) when: 1. Inside Residents 2, 4, and 30's, shared bathroom, the following were observed: - The bathroom sink was not fully secured or fully attached to the wall; - The bathroom wall on the right side had faux tiles not fully attached to the wall; and - The shower area water drainage cover was not secured to the floor. 2. Inside Residents 29 and 38's shared bathroom in, the following were observed: - The right-side wall in the shower area had an open area approximately five inches (unit of measurement) wide; - The lower section of the bathrom door had chipping paints; and - The bathroom wall had missing tiles approximately 10 inches wide. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Emergency Kits (E-Kit - an emergency storage box containing a small quantity of critical medications used in emergency situations) were not expired and were replaced within 72 hours according to the facility's policy and procedure. This failure had the potential to result in a delay in the administration of medications. In addition, this placed the residents at risk for receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were safe to self-administer medications, for two of three residents (Residents 4, and 35), reviewed for self-administration of medications. This failure had the potential for Residents 4 and 35 to self-administer medications unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of two residents reviewed (Resident 22), the cause of an injury of unknown origin (purplish skin discoloration on lateral right forearm) was investigated and reported in a timely manner. This failure had the potential to jeopardize the protection, health, and safety of Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure on safe smoking practices for two of four residents (Residents 17 and 27) reviewed for smoking when: 1. There was no staff supervision observed during Residents 17 and 27's smoke breaks; 2. There was no fire extinguisher observed in the smoking area. In addition, the fire blanket (sheet made of fire retardant material placed over a fire to smother it) was outdated, and the plastic covering of the fire blanket was observed to be torn and opened; and 3. Unsecured smoking materials such as cigarettes, loose tobacco and lighters, were observed to be in Residents 17 and 27's possession at all times. These failures had the potential to increase the residents' risks for smoking related injuries and accidental fires.

Inspectors wroteBased on interview and record review, the facility failed to conduct two Gradual Dose Reduction (GDR - a stepwise tapering of a dose) on psychotropic medications (medication capable of affecting the mind, emotions, and behavior) for two of three residents reviewed for GDR (Residents 35 and 38). This failure had the potential for the residents to have excessive duration, dose, and unnecessary use of the psychotropic medications.

Inspectors wroteBased of observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed and/or discarded when: 1. A multi-dose vial of one tuberculin PPD (a test used to detect tuberculosis (TB - an infectious lung disease), was found stored inside the medication refrigerator at the nurse station beyond the discard date. This failure had the potential for the residents to be administered a PPD past the beyond the discard date and could result in an inaccurate TB test results. 2a. Two eardrop medications for Residents 14 and 30 were found stored in the medication cart after the treatments were completed. In addition, a bottle of an opened Milk of Magnesia (MOM - a medication to treat constipation, upset stomach, and heartburn) suspension, labeled for a discharged resident's use, was stored in the medication cart; 2b. [...]