Meadowbrook Acres

In the surveyor’s words

From the most serious findings on record at Meadowbrook Acres, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Mar 17, 2022

  Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 54 Findings Included: During an interview on 03/14/22 on 12:50 PM, the Dietary supervisor (DS) #1, which was hired on 03/15/21, stated he was not a Certified Dietary Manager (CDM). He indicated he took the CDM class in 2015 and was supposed to test the day COVID hit. He further confirmed he has not rescheduled to take the test yet. During an interview on 03/15/22 at 9:32 AM DS #1 was asked how often the Registered Dietician visits the facility. […]

• No harm, potential for more than minimal, widespreadF882Mar 17, 2022

  Based on record review and staff interview, the facility failed to employee an Infection Preventionist (IP)who met all required qualifications. This failed practice has the potential to affect all residents currently residing in the facility. Findings Included: During record review it was determined the IP, RN #6 did not have the required certification on file. During an interview with RN #6 on 03/16/22 at 02:59 PM she states she has been in the IP position since 02/18/22 but is not yet been certified. She registered on 03/15/22 for the class and will be fulfilling the qualifications soon.

• No harm, potential for more than minimal, widespreadF812Jan 20, 2021

  Based on observation and staff interview the facility failed to store and serve food in accordance with professional standards for food safety. This practice had the potential to affect all residents currently residing in the facility. Facility Census: 45. Findings Included: a) Kitchen During a tour of the kitchen with the Certified Dietary Manager (CDM) on [DATE] beginning at 11:30 AM the following concerns were noted: Reach In Cooler: -- A quart container of Half and Half had a manufactured stamped expiration date of [DATE]. -- Two zip lock bags containing deli turkey were dated [DATE]. -- A zip lock bag containing prepared beef steaks was dated [DATE]. -- A container of pureed grapes was not dated. […]

• No harm, potential for more than minimal, patternF656Nov 6, 2025

  Based on observation, record review and staff interview the facility failed to develop and implement the care plan for applying bed rails to the beds. This was true for three (3) of the eleven (11) residents that were reviewed for bed rails. Resident Identifiers: #49, #30 and #19. Facility Census: 58 Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers. On 11/04/25 at 10:20 AM review of the care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. […]

• No harm, potential for more than minimal, patternF684Nov 6, 2025

  Based on record review, staff interview, and observation the facility failed to provide care in accordance with professional standards of practice, by not following doctors orders for side rail implementation and neuro checks. This failed practice was found true for (4) four of (4) four residents reviewed for fall interventions during the Complaint Survey Process. Resident identifiers #19, #30, #49, and #23. Facility Census 58.Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers ordered on 08/14/24. The care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. […]