Meadowbrook Village Christian Retirement Community

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) meeting was conducted within 48 hours for one of two residents (Resident 21) reviewed for baseline care planning. This failure had the potential for incomplete and lack of care interventions for residents in the event of a serious change of condition to potentially occur to residents after admission. In addition, the lack of communication among facility staff and resident or responsible party had the potential to affect the quality of care to the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure employee performance evaluations were completed annually for four of five Certified Nurse Assistants (CNA) reviewed for performance reviews. This deficient practice had the potential for CNAs to provide inadequate care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: 1. Food stored in the refrigerators and freezer were expired and did not have a label, 2. Food stored in the dry storage room were expired or mislabeled, 3. Drying rack had scoopers stored in a container with debris and a green cutting board with discolored center had deep knife marks. 4. A stand electric fan with black debris on the blades was in the kitchen facing the food prep area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1. Facility staff were unaware of the required Enhanced Barrier Precaution (EBP-an infection control strategy that mandate the use of gowns and gloves during high-contact resident care) for a resident (Resident 6) with an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine), 2. A stand electric fan with black debris on the blades was inside the kitchen food prep area. Cross reference F812 This failure had the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two residents reviewed for unnecessary medications were free from unnecessary use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: Resident 3 did not have an acceptable indication for use of seroquel (an antipsychotic medication that work to alter brain chemistry to reduce psychotic symptoms such as hallucinations [seeing things not there], delusions [irrational beliefs], paranoia [thoughts of others trying to harm of deceive] and disordered thinking), A gradual dose reduction (GDR- tapering of a medication's dosage to determine if the resident's symptoms can be managed on a lower dose or if the drug can be discontinued) for the use of seroquel was not completed (Resident 3). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to identify a resident's (Resident 10) need for occupational therapy for one of four residents reviewed for specialized rehab services (physical therapy, occupational therapy or speech therapy). This failure had the potential for a decline in the resident's functional status.

Inspectors wroteBased on interviews and record review, the facility failed to implement standardized data collection and reporting for their Quality Assurance Performance Improvement/Quality Assessment and Assurance (QAPI/QAA) program. This failure had the potential for facility areas of improvement to not be recognized and not progress toward resolution. During the Quality Assurance and Performance Improvement (QAPI) interview on 2/13/2026 at 12:30 p.m. with the facility Administrator (ADMIN), the ADMIN stated that each participant in the QAPI program brings forward concerns in their areas. The individual area leader decides the scope of their project and how data is recorded and shared. The ADMIN further stated .standardization would help everyone see and understand the results. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement Performance Improvement Plans (PIPs). The facility was not aware of the deficient practices identified during the recertification process for an unknown amount of time. This failure had the potential to not address high volume, high risk occurrences impacting residents' health and safety. During the Quality Assurance and Performance Improvement (QAPI) interview on 2/13/2026 at 12:35p.m. with the Director of Nursing (DON) and the facility Administrator (ADMIN), the DON stated, We do not have any performance improvement projects. During a review of the facility's policy and procedure titled Quality Assurance and Performance Improvement Plan dated April 2014, indicated .Authority.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Store foods appropriately in the dry storage room and freezer. 2. Cover facial hair while preparing food. These failures had the potential for food contamination and spoilage of residents' food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately clean the area around their kitchen dumpster. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Medications (med) were stored properly. 2. Medication Refrigerator temperatures were documented consistently for one of one medication refrigerator. 3. Medication room temperatures were documented consistently for one of one medication room. These failures had the potential for unsafe storage, contamination of medication and altered efficacy of resident medications.

Inspectors wroteBased on interview and record reviews, the facility failed to implement a water system that included Legionella testing for thirteen out of thirteen residents affected. This failure had the potential of affecting the health and safety of residents in the facility.

Inspectors wroteBased on interview and record review, the facility did not staff a Registered Nurse (RN) for eight consecutive hours per 24 hour period for 14 days. This failure had the potential to negatively impact Resident care due to lack of RN supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer an unexpired medication to one of 4 residents (Resident 3). This failure had the potential for Resident 3 to receive a less potent medication resulting in diminished effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to store a medication according to manufacturer instructions. This failure had the potential for the facility residents to receive a less potent medication resulting in diminished effectiveness in an emergent situation.

Inspectors wroteBased on observation interview and record review, the facility did not ensure confidentiality of the medical records for 12 of 12 sample residents (1, 2, 3,4, 6,7, 9, 10, 11,12, 116, 166). This failure had the potential to result in unauthorized access to confidential and protected health information.

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological interventions (actions or treatments that do not include the use of medicine) were implemented for three of five sampled residents (Residents 1, 2 and 6) that had been given psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 6 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 2. Resident 1 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 3. [...]