Meadowbrook Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 30, 2021

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the coroner ' s report, review of the Hospice record and staff interview, the facility failed to ensure a resident received the assistance of two staff during incontinence care. This resulted in Immediate Jeopardy when Resident #63 was rolled out of bed onto the floor during care by State tested Nursing Assistant (STNA) #113. The resident sustained serious life-threatening injuries of bilateral femur fractures and subsequently expired at a Hospice facility. The coroner ruled the resident ' s death an accident due to complications of bilateral femur fractures and a fall. This affected one (Resident #63) of three residents reviewed for falls. […]

• Actual harm, isolatedF684Feb 1, 2023

  Based on medical record review, interviews with facility staff and Nurse Practitioner (NP) #350, and review of the facility policy, the facility failed to monitor a residents bowel function. This resulted in Actual Harm for Resident #105 when the resident went multiple days with no recorded bowel movements and was subsequently treated at the hospital for severe fecal impaction. This affected one (Resident #105) of three residents reviewed for constipation. The census was 97. Findings include: Review of the medical record for Resident #105 revealed an admitted [DATE]. Diagnoses include multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction, quadriplegia, and neuromuscular dysfunction of bladder. Resident #105 discharged from the facility on 01/14/23. […]

• Actual harm, isolatedF684Jul 8, 2022

  Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's diabetes was monitored. This resulted in Actual Harm when Resident #40 was found with extreme lethargy and subsequently hospitalized with a blood sugar level of 1,211 milligrams per deciliter (mg/dL). This affected one resident (#40) out of three residents reviewed for diabetes. The facility census was 107. Findings Included: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive minimum data set (MDS) assessment revealed Resident #40 was cognitively intact. Resident #40 required supervision only for eating. […]

• Actual harm, isolatedF686May 5, 2021

  Based on observation, staff interview, record review, National Pressure Injury Advisory Panel (NPIAP) recommendations and facility policy review, the facility failed to ensure a resident was provided proper positioning in bed with pressure relief to the feet to prevent the development of an avoidable pressure ulcer. This resulted in actual harm when Resident #79 developed an avoidable pressure ulcer to her left fourth toe that progressed from a Stage II to a Stage IV pressure ulcer. This affected one Resident (#79) of four residents reviewed for positioning. The facility identified four additional residents (#06, #37, #87 and #89) with facility acquired pressure ulcers. The total facility census was 116. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, staff interview, and policy review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness. This had the potential to affect all of the residents residing in the facility with the exception of for eight facility-identified (Residents#1, #8, #15, #20, #43, #67, #91, and #124) with orders for nothing by mouth. The facility census was 107 residents. Findings include: 1. Observation n 06/01/26 at 8:13 A.M. of the freezer next to the grill line revealed it included the following items which had ice crystals on them: two bags of chopped carrots, one bag of fish, two bags of raw chicken, one bag of raw pork, three bags of hot dogs, one bag of sausages, one bag of beef. Interview on 06/01/26 at 8:20 A.M. […]