Meadowbrook Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Oct 25, 2024

  Based on observation, interviews, and record review conducted during recertification and abbreviated survey (NY00329299), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for 5 (Residents #76, 104, 119, 139, and 177) of 44 residents reviewed for comprehensive care plans. Specifically, (a.) Resident #76 care plan interventions were not implemented based on recommendations from the interdisciplinary team to reduce falls and injuries after a fall and the resident had subsequent falls, (b.) Resident #104 care plan did not include interventions and goals for dementia care, (c.) Resident #119 had fallen several times and… […]

• No harm, potential for more than minimal, patternF657Oct 25, 2024

  Based on observations, record review, and interviews during a recertification survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions for 4 (Resident #'s 50, 53, 76, and #177) of 44 residents reviewed. Specifically, (a.) for Resident #53, the comprehensive care plan for Clotridoides or Clostridium difficile infection (a bacterium that causes diarrhea and inflammation of the colon) was not updated when the infection had resolved; (b.) for Resident #76, the fall care plan was not revised after the most recent Minimum Data Set Assessment; the comprehensive care plan for behaviors did not include a psychiatric consult or on-going… […]

• No harm, potential for more than minimal, patternF725Oct 25, 2024

  Based on observation, record review, and interviews during the recertification and abbreviated survey (Case #s NY00326260, NY00329259, NY00334623, and NY340304), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nurse Aides were not met every day on multiple shifts and multiple units, from 10/05/2024 to 10/20/2024. […]

• No harm, potential for more than minimal, patternF759Oct 25, 2024

  Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 3 (Resident #s68, 182 and 199) of 6 residents observed during a medication pass for a total of 34 observations. This resulted in a medication error rate of 38.24%. This is evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified by the physician. Nurses must take every safety precaution when administering medications. […]

• No harm, potential for more than minimal, patternF761Oct 25, 2024

  Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates, and (b) a medication cart was left unattended and unlocked. This was evident for 3 (Aspen, Subacute, and Orchard Units medication carts) out of 3 medication carts reviewed. This was evidenced by: The facility's Policy and Procedure titled Medication Administration reviewed 2/2020 documented Nurses were required to adhere to the following: The expiration date on the medication label must be checked prior to administering. […]