Meadow Brook Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Meadow Brook Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 22, 2024

  Based on observation, interview, and record review it was determined, for 10 out of 40 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. Upon return to the facility the resident's cervical collar was removed by Certified Nursing Assistant(s) (CNA) during grooming and bathing cares. […]

• Immediate jeopardy, isolatedF726Feb 22, 2024

  Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was transported via the facility van and the wheelchair was not secured properly inside the vehicle which resulted in the resident falling backwards causing hyperextension of his neck. The resident was diagnosed with central cord syndrome and edema at the level of C6 and C7 of his cervical spine. […]

• Actual harm, patternF867Feb 22, 2024

  Based on observation, interview, and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. Specifically, multiple areas of immediate jeopardy and harm were identified on the recertification survey. Resident identifiers: 3, 6, 17, 19, 21, 28, 29, 31, 34, 39, 90, 91, 92, 93, 94, 96, and 97. Findings include: 1. Based on observation, interview, and record review it was determined, for 10 out of 40 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. […]

• Actual harm, isolatedF578Feb 22, 2024

  Based on interview and record review, the facility did not ensure that 1 of 40 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, one resident with an advanced health care directive received treatment that was documented as against the resident's wishes. This resulted in a finding of harm. Resident identifier: 39. Findings include: Resident 39 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, interstitial pulmonary disease, acute and chronic respiratory failure, severe protein calorie malnutrition, pulmonary fibrosis, endocarditis, transient ischemic attack, end stage heart failure, atrial fibrillation, pulmonary hypertension, abnormal weight loss, delirium, benign prostatic hypertension,… […]

• Actual harm, isolatedF624Feb 22, 2024

  Based on interview and record review, the facility did not provide and document sufficient preparation to 2 of 40 sampled residents to ensure safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment was discharged to a hotel room, but was subsequently seen at a local emergency room after becoming lost. This resulted in a finding of harm. In addition, one resident left on a leave of absence, and was not oriented for discharge upon return to the facility. Resident identifiers: 94 and 97. Findings include: HARM 1. Resident 94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Wernicke's encephalopathy, dementia, major depressive disorder, other amnesia, and history of traumatic brain injury (TBI). […]