Meadowbrook Manor - Lagrange

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 13, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident identified with confusion, poor safety awareness, ambulatory, and had verbalization of wanting to exit the facility, was provided supervision to prevent elopement from the facility. The facility also failed to ensure the door on the ground floor leads to courtyard and main street was in good repair and had a working alarm system to alert facility staff of a resident attempting to exit the facility. This failure resulted in R1 eloping from the facility without being witnessed by facility staff during the early hours on December 29, 2024. This applies to 1 of 7 residents (R1) reviewed for risk of elopement in the sample of 7. […]

• Actual harm, isolatedF684Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to follow their wound prevention and healing policy and resident shower/bathing policy by failing to identify and assess a resident's skin for an open wound for one (R24) of four residents reviewed for wound care. 2. Failed to provide a resident with services to avoid clinical complications by failing to adequately access a resident's change in condition, failed to promptly send a resident to the hospital after receiving an order and failed to report critical lab result to the attending physician. […]

• Actual harm, isolatedF686Dec 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents who developed facility-acquired pressure ulcers were assessed by the wound care physician/NP-Nurse Practitioner; failed to ensure the residents received nutritional interventions to promote wound healing; failed to put interventions in place to prevent pressure ulcers from deteriorating; failed to provide wound care treatments as ordered by the physician; and failed to follow their policy to do a root cause analysis for residents with facility-acquired pressure ulcers. This failures resulted in R1's facility-acquired pressure ulcer increasing in size, and R1's DTI (Deep Tissue Injury) progressing to an unstageable pressure ulcer. […]

• Actual harm, isolatedF689Oct 25, 2024

  Based on observation, interview, and record review, the facility failed to safely transfer a resident while using a mechanical lift. As a result of this failure, R1 sustained a laceration to the head and fracture of the thoracic 8 and 12 vertebral bodies after falling. R1 was transferred to the local hospital and received 2 staples to the back of R1's head. This applies to 2 of 6 residents (R1 and R7) reviewed for falls and accidents. The findings include: On 10/22/24 at 11:15 AM, R1 was observed in bed in her room. R1 said fall incident happened on a Thursday, which was her shower day. R1 said 2 Certified Nurse Aides (CNAs) transferred her using the mechanical lift from the bed to the shower chair and gave her a shower. R1 has a shower in her room. […]

• Actual harm, isolatedF689Nov 20, 2023

  Based on interview and record review, the facility failed to follow the plan of care regarding the required number of staff assistance during bed mobility of a resident. This failure resulted in R1 sustaining an acute closed displaced supracondylar fracture of the distal end of the right femur after R1 fell off the bed during care on 11/4/2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 as an [AGE] year-old resident, with diagnoses included multiple sclerosis, idiopathic gout, quadriplegia, atherosclerotic heart disease, chronic obstructive pulmonary disease, periprosthetic fracture around internal prosthetic right knee, vitamin D deficiency, vitamin B12 deficiency, anemia,… […]