Meadow Brook Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Meadow Brook Medical Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 25, 2025

  Based on observation, record review, and interviews, the facility failed to prevent staff to resident abuse for one Resident (#27) of two residents reviewed for abuse. This deficient practice resulted in untreated physical pain and psychosocial harm based on the reasonable person concept.Findings include: Resident #27 (R27)Review of R27's Electronic Medical Record (EMR) indicated R27 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) with agitation, anxiety, chronic pain syndrome,… […]

• Actual harm, isolatedF689Sep 25, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care during functional transfers and mealtimes for two Residents (#38 and #106) of eight residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #38 experienced a fall with fracture and head contusion. Findings include: Resident #38 (R38) Review of R38's face sheet, revealed original admission to the facility on 5/2/25 with medical diagnoses including diabetes mellitus, hypertension, muscle weakness, and gout. […]

• No harm, potential for more than minimal, patternF880Nov 21, 2022

  Based on observation, interview and record review, the facility failed to implement proper infection control measures during an outbreak of influenza on one household (Unit A). This deficient practice resulted in the potential for continued spread of influenza to the other residents residing within the household. Findings Include: Resident #9 Review of Resident #9's Electronic Medical Record (EMR) revealed an admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's 9/30/22 Minimum Data Set (MDS) assessment revealed she required extensive one person assist for transfers, dressing and personal hygiene. Resident #9 scored a 3/15 on the Brief Interview for Mental Status (BIMS) score indicating she was severely cognitively impaired. […]

• No harm, potential for more than minimal, patternF578Aug 25, 2021

  Based on interview and record review, the facility failed to assure Advanced Directives were periodically reviewed and updated annually for six Residents (#10, #27, #39, #43, #71, #79) of 24 residents reviewed for advanced directives. This deficient practice resulted in the potential for inaccurate designation of residents' medical decisions pertaining to life-sustaining interventions. Findings include: Resident #10 Review of Resident #10's Electronic Medical Record (EMR) revealed an Advanced Directive form titled, Do-Not-Resuscitate [DNR] Order , signed by Resident #10, their Durable Power of Attorney (DPOA), and their physician on 8/11/17. […]

• No harm, potential for more than minimal, patternF880Jan 27, 2021

  Based on observation, interview, and record review, the facility failed to ensure appropriate COVID-19 infection control practices were in place pertaining to restriction of entry into the facility and the staff screening process for two of four employees reviewed for employee screening. This deficient practice put staff and residents at increased risk for exposure to the COVID-19 virus. Findings include: On 1/25/21 at 11:33 a.m., the facility's main entrance door was observed to be open. This Surveyor was able to enter through the outer door and go into the vestibule. Employee screening forms were observed for employees to complete prior to starting their shifts. The vestibule door automatically opened, which allowed direct access to the facility. […]