Meadowbrook Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627Jul 8, 2025

  Based on closed medical record review, review of the facility Resident Transfer and Discharge Policy and interviews, the facility failed to provide a safe discharge to an appropriate location for Resident #49. On 05/20/25 Resident #49 was discharged to a homeless shelter with no referral for follow up care, no access to transportation and no evidence the resident's representative/emergency contact was involved in the discharge planning process or aware of the resident's discharge to the homeless shelter. In addition, there was no evidence Resident #49 was safe to discharge to this location. […]

• No harm, potential for more than minimal, widespreadF727Apr 28, 2026

  Based on interview, and review of staffing schedules, the staffing tool and the facility assessment, the facility failed to ensure a registered nurse (RN) was in the facility at least eight consecutive hours a day, seven days a week. This had the potential to affect all 50 residents residing at the facility.Findings include: Review of staffing schedules from 01/01/26 to 04/21/26 revealed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool from 04/05/26 to 04/11/26 completed on 04/21/26 at 12:00 P.M. with Administrator, Human Resource (HR) #624, and Scheduler/HR Assistant #623 revealed there was no RN coverage for at least eight consecutive hours on 04/05/26. Interview on 04/21/26 at 12:00 P.M. and 1:47 P.M. […]

• No harm, potential for more than minimal, widespreadF809Nov 23, 2022

  Based on meal schedule review, menu review, staff interview, and observation, the facility failed to provide a substantial evening snack when greater than 14 hours elapsed between the evening meal and breakfast. This had the potential to affect 33 out of 33 residents that received meals from the kitchen. The facility census was 33. Findings include: Review of scheduled mealtimes revealed dinner was at 4:45 P.M. for the second floor and at 5:05 P.M. for the first floor, and breakfast was at 7:30 A.M. for the second floor and 7:50 A.M. for the first floor. Review of the 11/20/22 to 11/26/22 facility menus revealed evening snacks were not listed on the menu. Interview on 11/22/22 at 9:00 A.M. […]

• No harm, potential for more than minimal, patternF558May 29, 2025

  Based on observation, staff interview, record review, and review of facility policy, the facility failed to ensure call lights were within reach of Resident #3, #27, #34 and #43. This affected four residents of 19 residents reviewed for accommodation of need. The facility census was 47. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 11/07/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), hemiplegia affecting right dominant side, major depressive disorder, and insomnia. […]

• No harm, potential for more than minimal, isolatedF600Apr 28, 2026

  Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the state survey agency database for SRI reporting, the facility investigation and facility policy, the facility failed to ensure residents were free from sexual abuse. This affected three residents (Resident #22, #53 and #54) out of six residents reviewed for abuse. The facility census was 50.Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. […]