Meadowbrook Health & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 2, 2026

  Based on record review, observation, and interviews with staff, Nurse Practitioner, and the Psychiatric Nurse Practitioner, the facility failed to provide effective supervision for a resident who had cognitive impairment, alcohol induced dementia, and a court appointed Guardian. On 12/2/2024 Resident #120 told the Director of Nursing he was upset because he had been told by a staff member that he was going to be moved to the secured unit. Later that same day Resident #120 stacked patio furniture in the enclosed courtyard and then proceeded to climb onto an awning, then up to the roof of the facility. Resident #120 was observed by staff to be running around on the roof and sitting on the edge of the roof with his legs dangling over the edge of the roof. […]

• Immediate jeopardy, isolatedF689Sep 3, 2021

  Based on hospital record review, facility record review, observation, and staff, Nurse Practitioner and Physician interviews the facility failed to provide supervision to prevent 1 of 1 residents, Resident #1, with a history of eating items from the trash, from ingesting an unidentified object. The facility also failed to assess Resident #1 for symptoms of potentially life-threatening diseases since the unidentified object was alleged to be a mouse. Immediate Jeopardy began on 8/9/2021, when Resident # 1 ingested an unidentifiable object and the facility failed to immediately and effectively respond to the situation. The Immediate Jeopardy was removed on 8/14/2021 when the facility provided and implemented a credible allegation of immediate jeopardy removal. […]

• Actual harm, isolatedF600Jan 19, 2024

  Based on record review, observations and resident, staff, Police Officer, Nurse Practitioner and Medical Doctor interviews, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 3 residents investigated for abuse (Resident #7). Resident #7 reported to the facility that Nurse Aide (NA)#1 had punched her in her right eye. Resident #7 revealed that Nurse Aide #2 was present during this incident and witnessed the allegation. After this incident Resident #7 had a circular reddish, purple bruise below her right eye and reported she felt angry and upset at the time of the incident. […]

• Actual harm, isolatedF686Sep 3, 2021

  Based on record review, family, Nurse Practitioner and staff interviews, the facility failed to assess and treat 1 of 3 residents, Resident # 2, for skin breakdown which was discovered when Resident #2 was admitted to the hospital with increased blood glucose level and a bloodstream infection. Findings included: Review of Resident #2's Medical Record revealed she was admitted to the facility on [DATE] and discharged to the hospital on 7/4/2021. Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse that completed Resident #2's Admission Assessment was not available for interview. Resident #2's Medical Record further revealed she did not have a skin assessment completed after her initial Admission Assessment. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2023

  Based on observations and staff interviews the facility failed to ensure dietary staff contained facial hair for staff members with beards serving residents food for the preparation of resident's lunch meal trays. The result of the failure to contain facial hair during meal tray preparation and serving had the potential to affect all residents in the facility who would receive a lunch meal tray, and 138 of 139 residents received meal trays. Findings included: On 4/3/2023at 11:35 am an observation of the dietary staff preparing and serving the lunch meal trays for residents revealed the dietary staff failed to contain facial hair for staff with beards, during the observation: The Dietary Manager was preparing trays for plates and handling the plates after the cook served food onto the… […]