Meadowbrook Healthcare and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF882Jul 18, 2023

  Based on facility policy, record review, and interview the facility failed to maintain a qualified Infection Preventionist with specialized training and failed to report an outbreak of COVID to the local health department during July of 2023 for 5 of 6 (Resident #1, 2, 3, 4, and 5) sampled residents, which had the potential to affect all residents in the facility. Census of 62. The finding include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per… […]

• No harm, potential for more than minimal, isolatedF554Feb 22, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to complete an assessment for self-administration of medications for 1 (Resident #38) of 5 residents reviewed for medication administration. Findings included: A facility policy titled, Self-Administration of Medication, revised 01/01/2025, indicated, If the resident indicates a desire to self-administer medication, he/she shall be assessed utilizing the Self-Administration of medication assessment found under the assessment tab in the EHR [electronic health record]. A Face Sheet revealed the facility admitted Resident #38 on 07/07/2022. […]

• No harm, potential for more than minimal, isolatedF880Feb 22, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 (Resident #9) of 25 residents reviewed for EBP. Findings included: A facility policy titled, Transmission Based Precautions, revised 01/01/2025, indicated, It is our policy to take appropriate precautions to prevent transmission of infectious agents. 'Enhanced barrier precautions' (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions: 2. An order for enhanced barrier precautions shall be obtained for residents with any of the following: i. […]

• No harm, potential for more than minimal, isolatedF580Jul 18, 2023

  Based on facility policy review, medical record review, and interview, the facility failed to report a change in condition for a resident to the resident's representative for 1 of 6 (Resident #4) sampled residents. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .visitors .The RNs [Registered Nurse] and LPNs [Licensed Practical Nurse] participate in surveillance through assessment of residents and reporting changes in condition .Residents, family members, and visitors are provided information relative to the rationale for the isolation,… […]

• No harm, potential for more than minimal, isolatedF655Jun 9, 2021

  Based on facility policy review, medical record review, and interview the facility failed to implement a baseline care plan for [CONDITION(S)] medications (antidepressant and antianxiety) for 1 of 19 residents (Resident #185) receiving [CONDITION(S)] drugs. The findings include: Review of the undated facility policy, Baseline Care Plan, revised 11/2020, showed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .the baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [MEDICAL RECORD OR… […]