Meadowpark Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review the facility failed to ensure grievances regarding a room change were addressed in a timely manner for two residents (#14 and #34) of 20 sampled residents. Findings Included: During a tour on 05/11/2026 at 09:02 AM, Resident #14 and Resident #34 reported verbally cursing each other and not wanting to be roommates. Resident #14 explained not being able to get along with the roommate. Resident #34 stated the situation had been reported to the staff and both stated being agreeable to a room change at the time. During an interview on 05/13/2026 9:09 AM, Staff E, Licensed Practical Nurse (LPN)/ Unit Manger (UM), explained being notified by Resident #34's family member, of Resident #14 cursing at Resident #34. Staff E stated having spoken to the Social Services Director (SSD) and stated a grievance had been opened for the situation. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care plans were revised to reflect personal care preferences related to contracture management and use of orthotics/splints for one resident (#2) out of 20 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure nail care was offered/provided for one resident (#2) of 20 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure call light buttons/call light cords were placed within reach for three residents (#2, #59 and #97) out of forty-three sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the grievance process was conducted to resolve grievances in a timely manner for five residents (#3, #5, #6, #7, and #8) of eight sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure resident rights were honored for two residents (#3 and #4) out of 3 residents sampled related to removing residents from isolation precautions according to the standards of practice.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the development of a person-centered care plan related to shoulder replacement and pain during care for one resident (#2) of eight sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor the right of the resident's representative to participate in the development of the resident's care plan for one resident (#5) out of eight sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) services related to toileting for two residents (#2 and #5) out of eight sampled residents.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I for eight (Residents #50, #2, #69, #3, #22, #54, #65, and #56) of eight residents admitted with mental health and/or cognitive diagnoses sampled for PASRR.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans for six (Residents #77, #313, #2, #50, #22, and #27) of twenty eight sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facilty failed failed to obtain and document current body weight of two (Residents #22 and #65) out of thirty-six sampled residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a Medication Regimen Review was completed for one month of three months reviewed for three (Residents #27, #77, and #56) of five sampled residents and failed to ensure a recommendation was adequately and accurately implemented for one (Resident #27) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #24) of one sampled resident received supervision and assistance with eating during all three meals.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the urinary drainage bag was maintained in a sanitary manner and drained every shift according to the plan of care for one (Resident #22) out of 10 residents with urinary catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #26) of one sampled resident, who was diagnosed and assessed with Post Traumatic Stress Disorder (PTSD), received care and services in accordance with professional standards of practice to minimize triggers and/or re-traumatization.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure a safe, clean, and homelike environment for eight (120, 124, 135, 138, 140, 143, 148, and 246) of 11 resident bathrooms, seven (112, 120, 124, 132, 138, 225, and 246) of 11 resident room baseboards, and three (first and second floor) of three community shower/spa rooms.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-eight medications were observed, and eleven late medications were verified for one (Resident #206) of six (6) residents observed. These late medications constituted a medication error rate of 39.29 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified existence related to dining for one (Resident #24) out of seven sampled residents. Measures were not taken to ensure assistance was provided during dining to support the resident's dignity, and labels such as a feed was used by facility staff when referring to residents that needed help with eating.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that a resident centered care plan was developed and implemented related to Oxygen use for one (Resident #53) of five sampled residents and failed to implement fall interventions for one (Resident #68) of forty-two residents in the sample group.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Intravenous (IV) care according to professional standards for two (Resident's #71 and #357) of four sampled residents by failing to ensure the IV dressings remained intact. Findings Included: 1. During an interview and observation of Resident #71 on 9/13/21 a.m. at 11:45 a.m., the resident stated she received IV medication for a left hip infection. The right upper arm IV dressing was dated in black marker, difficult to read as 9/7/21 or 9/9/21. During an interview and observation of Resident #71 on 9/14/21 9:30 a.m., she stated she received her IV antibiotic this morning and the IV dressing remained with the same date. During observation on 9/15/21 at 11:48 a.m., the IV dressing was loose on the right upper inner arm and not completely intact on the outer edge. The date was the same on the dressing. [...]