Meadowbrook Rehabilitation Hospital

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with two reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent avoidable accidents when direct care staff used the incorrect sling size while attempting to transfer Resident (R) 112, a quadriplegic (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) resident with a history of traumatic brain injury. On 08/04/25 at 08:00 PM, Certified Nurse Aide (CNA) N and CNA O attempted to transfer R112 from her wheelchair to her bed, used the wrong sling size, the mechanical lift tipped over, and R112 fell to the floor from the lift's highest position. [...]

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with three medication rooms. Based on observation, record review, and interviews, the facility failed to secure medication carts containing residents' insulin (a hormone that lowers the level of glucose in the blood) pens and needles, residents' scheduled medications, and over-the-counter medication.

Inspectors wroteThe facility had a census of 109 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 15, R12, R80, R13, and R54's protected health information (PHI) private on a medication cart parked in the main dining room.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents. Based on interviews and record reviews, the facility's direct care staff failed to verify and utilize the appropriate Hoyer lift sling while transferring Resident (R) 112, resulting in a non-injury fall from the Hoyer lift.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician-ordered laboratory tests were obtained as ordered for Resident (R) 15 and R9. The facility also failed to consistently take and record blood pressures and pulse for R5's beta blocker (a medication to slow down your heart rate and reduce the force of your heart's contraction).

Inspectors wroteThe facility identified a census of 109 residents, six residents on a puree textured diet. One resident received a double portion of their pureed diet, so the facility prepared seven pureed servings. Based on observation, record review, and interviews, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory tests to monitor antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) for Resident (R) 9 were completed. The facility also failed to ensure the physician had documented a rationale with the risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorders characterized by a gross impairment in reality testing) medication with no gradual dose reduction for R7.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with four sample residents reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17, R87, and their representatives were provided bed hold and a written notification of transfer, as soon as practicable, upon their transfer to the hospital. The facility failed to ensure R76, and his/her representative was provided a bed hold, as soon as practicable, upon transfer from the facility.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents. Based on observation, record review, and interviews, the facility failed to identify the significant change in Resident (R) 54's condition and complete a comprehensive Significant Change Minimum Data Set (MDS) with the discontinuance of hospice services.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to consistently follow a physician's order for daily weight monitoring for fluid overload and further failed to ensure Resident (R) 2's fluid restriction was monitored per the physicians' orders.

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to monitor the low-air-loss (a special type of medical mattress that uses microscopic holes to provide a constant, slow airflow) mattress for Resident (R) 54 and further failed to provide a pressure-reducing device for R16's wheelchair. [...]

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 16 received services and treatment for his right-hand contracture (abnormal permanent fixation of a joint or muscle) to prevent an avoidable reduction of range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations had been reviewed and addressed by the physician within 30 days for Residents (R) 15 and R9. The facility also failed to ensure the CP had identified and reported the physician-ordered laboratory tests had not been followed for R15 and R9.

Inspectors wroteThe facility had a census of 109 residents. The sample included 22 residents. Based on record review and interviews, the facility failed to submit complete and accurate staff information through Payroll-Based Journal (PBJ) as required.

Inspectors wroteThe facility identified a census of 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, a cognitively impaired resident, remained free from staff-to-resident abuse. On 10/31/24, Certified Nurse Aide (CNA) M and CNA N got R1 ready for a shower. R1 started yelling and swatted at CNA M. CNA M swatted at R1 in return. After CNA M and CNA N got R1 up with the Hoyer lift (full body mechanical lift) and into the shower chair. R1 yelled loudly, and CNA M put her hand on R1's mouth and told R1 to hush. This deficient practice resulted in impaired psychosocial well-being for R1 and placed R1 at risk for continued abuse.

Inspectors wroteThe facility identified a census of 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure staff immediately reported staff-to-resident abuse for R1 on 10/31/24. This deficient practice placed R1 at risk for further abuse.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to ensure its certified nurse aides (CNA) received 12 hours in-services annually as required. This deficient practice placed the 100 residents of the facility at risk for inadequate care.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to promote and provide dignity for Resident (R) 28, who had an uncovered urinary catheter (insertion of a catheter into the bladder to drain the urine) bag. The facility further failed to promote dignity and respect during dining for the 15 residents seated in the dining room when staff discussed their personal issues and looked at their cell phones when assisting residents in eating the meal. These deficient practices placed the residents at risk for an undignified experience and impaired quality of life.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to provide activities of daily living (ADL)care and assistance to Resident (R) 28, R38, R18, and R61. This deficient practice placed the residents at risk for poor hygiene and impaired dignity.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to complete competency assessments for staff to ensure staff possessed the skills and abilities necessary to provide care to facility residents. This placed the residents who used mechanical lifts at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to discard outdated medication in one of two medication rooms. This placed the residents at risk of ineffective medications.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of two kitchens. This placed the residents who received their meals from the facility's south kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk to acquire, spread, and experience complications from the pneumococcal disease.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens' plate warmer was in safe and operable condition. This placed the residents who received their meals from the south kitchen at risk of receiving cold food.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to accommodate one resident's, Resident (R) 61's preferences when staff delivered R61's meal trays with the other facility room trays even though R61's representative would not be coming until later to feed the resident. This placed the resident at risk for impaired nutrition as well as decreased quality of life.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to report to the State Agency (SA) within the required timeframe Resident, (R)96's black eye received from an unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate an injury of unknown origin for one resident, Resident (R) 96, who had a black eye. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents with three reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care (LTC) Ombudsman (a person who advocates for residents of nursing homes), as required, of Resident (R) 76's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents with three reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide Resident (R) 76 and/or the resident's representative with the facility Bed Hold upon a facility-initiated discharge/transfer to the hospital. This placed the resident at risk for impaired rights.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to develop a care plan for Resident (R) 96, who had tremors. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to revise a care plan with effective person-centered interventions for one resident, Resident (R) 18, who had falls related to toileting and failed to revise a care plan for R61, who no longer had enhanced barrier precautions. This placed the residents at risk for further injury and unmet care needs.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents, with one reviewed for restorative therapy. Based on observation, record review, and interview, the facility failed to provide one sampled resident, Resident (R) 61, restorative therapy as care planned. This placed the resident at risk for a decline in mobility and function.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement the fall prevention interventions for Resident (R) 18, who had falls related to toileting, and failed to provide padded bed rails for R96, who had tremors and hit the bed rails which resulted in bruising. This deficient practice placed the resident's at risk for injury.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to provide the physician-ordered residual checks and water flushes for Resident (R) 14's feeding tube (tube for introducing high-calorie fluids into the stomach). This deficient practice placed R14 at risk for aspiration (inhaling liquid or food into the lungs) and inadequate hydration.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 18's blood pressures outside of physician-ordered parameters. This deficient practice placed R18 at risk for unnecessary medication side effects.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to hold metoprolol (a blood pressure medication) when blood pressures were out of parameters for one resident, Resident (R) 18. This placed R18 at risk for physical decline and medications complications.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to obtain a physician rationale and risk versus benefit explanation for the continued use of risperidone (antipsychotic medications used to treat major mental conditions that cause a break from reality) for Resident (R) 31. This deficient practice placed the resident at risk of receiving unnecessary antipsychotic drugs.

Inspectors wroteThe facility had a census of 100 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to post the nursing staffing information in each facility building daily.

Inspectors wroteThe facility identified a census of 39 residents. Based on observation, record review, and interviews, the facility failed to perform required cooking equipment checks, store food in a sanitary manner, and ensure kitchen appliances are wiped down daily. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Finding Include: -During the initial inspection of the kitchen on 03/14/22 at 07:10AM the facility's dishwasher sanitation log from 12/2021 through 03/2022 had missing sanitation documentation on 24 occasions (12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/25, 2/26, 2/27, 2/28, and 2/29). [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide care and services to maintain Resident (R) 16's highest level of function, by not maintaining urostomy (diversion of urine away from a diseased or defective bladder through a surgically created opening, or stoma, on the skin) supplies. This placed the resident at risk for physical discomfort, and negative psychosocial impact.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. One resident, (R)27, was sampled for the accuracy of assessments. Based on observation, record review and interview the facility failed to ensure that R27 received an accurate Minimum Data Set (MDS) assessment when the facility incorrectly coded an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) as an antidepressant (class of medication s used to treat mood disorders).

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to revise the comprehensive care plan to include antipsychotic medication (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]) use and antibiotic therapy (class of medication used to treat bacterial infections) for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) for Resident (R) 27, which had the potential for alteration of continuous care among nursing home staff, that could result in adverse consequences related to safety, adverse side effects or injury.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents with six residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for one resident who required assistance from staff to complete the care. This deficient practice placed resident (R)27 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 39 resident. The sample included 12 residents. One resident, (R) 40, was sampled for the prevention of decline in range of motion (ROM). Based on observation, record review, and interview the facility failed to ensure staff applied R40's splint and brace as ordered by the physician, which placed r40 at risk for further decrease in ROM.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure the physician documented a clinical indication for antipsychotic medication (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]) use as recommended by the Consultant Pharmacist (CP) for Resident (R) 27, which had the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure an appropriate diagnosis for antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) for Resident (R) 27, which had the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents with 12 reviewed for infection control. Based on observation, record review, and interviews, the facility failed to identify and implement transmission-based precautions and personal protective equipment (PPE) for Resident (R) 22 and R23 and failed to ensure adequate hand hygiene during peri-care for R22. This deficient practice placed the residents at risk for complications related infectious pathogens. Findings Include: -On 03/10/22 at R23's Lab Report indicated his urine culture tested positive for methicillin-resistant staphylococcus aureus infection (MRSA- drug resistant contagious bacteria). On 03/14/22 at R22's Lab Report indicated his urine culture tested positive for MRSA. [...]