Meadowbrook Behavioral Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. Resident 1 told Resident 2 to stop, and Resident 2 was masturbating in front of Resident 1 and got on top of Resident 1 while Resident 1 laying down. Resident 2 touched and sucked on Resident 1's breasts. […]

• Immediate jeopardy, isolatedF607May 30, 2025

  Based on observation, interview, and record review, the facility failed to implement its Abuse Prohibition Policy and Procedure (P&P) to prohibit, prevent, and investigate allegations of sexual abuse (non-consensual contact of any type or sexual harassment), for two of six sampled residents (Resident 1 and Resident 2) by failing to ensure Resident 1 was free from sexual abuse from Resident 2 who had a history of exchanging money for sex while residing at the facility. On [DATE] at approximately 8:13 PM Resident 2 went inside Resident 1's room while Resident 1 (who did not have the capacity to consent for sexual activities) was laying down and Resident 2 pulled out his genitals. […]

• Actual harm, patternF600Apr 4, 2025

  Based on interview and record review, the facility failed to protect two of six sampled residents'(Resident 1 and Resident 4) right to be free from physical abuse when: - On 3/21/2025, Primary Counselor (PC) 1 physically fought Resident 1 inside Resident 1's assigned room and - On 4/2/2025 Resident 5 hit Resident 4 in the nose These deficient practices resulted in Resident 1 and Resident 4 being subjected to abuse and requiring x-rays after the assault and had the potential for all residents (77) to feel powerless and unprotected in the facility. Findings: A. […]

• Actual harm, isolatedF600Jul 22, 2025

  Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (when a person has abnormally high blood pressure that's not the result of a medical condition), paranoid schizophrenia (Persistent, false beliefs, often centered around persecution, where the individual believes they are being harmed or negatively affected by others). During a review of Resident 1's History and Physical (H&P) dated 10/30/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions, however, he can make needs known. […]

• No harm, potential for more than minimal, widespreadF727Jan 12, 2024

  Based on Observation, interview, and record review, the facility failed to designate a registered nurse (RN) to serve as full-time Director of Nursing (DON) from 10/13/2023 until 12/26/2023. This deficient practice had the potential to result in the facility's inability to establish nursing standard of practices, compliance with the Stated and Federal agencies, handle emergencies in the facility, complete incident reports, initiate investigations on incidents, manage the entire nursing department and assume the responsibility for resident care in the absence of a physician, and the assume the responsibility of an Administrator in the absence of an Administrator. […]