Meadowbrook Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF679May 15, 2023

  Based on observation, interview and record review, the facility failed to ensure activities were being provided to 48 of 48 residents ( Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48) residing in the facility. This failure resulted in psychosocial harm for four residents (Resident 1, Resident 2, Resident 3, and Resident 12). Residents 1, 2, 3, and 12; verbalized being bored, frustrated, and felt no joy while at the facility. […]

• Immediate jeopardy, patternF689May 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure a system was in place in ensuring supervision was provided for 10 of 10 residents (Residents 1, 3, 4, 5, 6, 7, 8, 9,10, 11) during smoking activities. The facility disclosed being a non-smoking facility; however, had allowed residents to smoke cigarettes unsupervised while at the facility. The facility has no policy and procedure in place on how to manage residents smoking cigarettes. This failure of the facility resulted in Resident 3 sustaining burn on her nose while smoking without supervision. In addition, this failure could potentially jeopardize the health and safety of the other nine residents (Residents 1, 4, 5, 6, 7, 8, 9, 10, and 11) while smoking cigarettes. […]

• Immediate jeopardy, patternF812Nov 9, 2021

  Based on observations, interviews, and record reviews, the facility failed to maintain an environment that meets professional standards for food service safety and ensure the residents' food was prepared under sanitary conditions, when: 1. Unpasteurized eggs (have not been heat treated to eliminate bacteria), served to two(Residents 2 and 4) of 49 residents on oral diet , were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of Salmonella infection (bacterial disease that affects the intestinal tract. […]

• Immediate jeopardy, isolatedF684Nov 9, 2021

  Based on observation, interview, and record review, the facility failed to provide on-going skin assessment, monitoring, and provide necessary interventions, for one of four residents' (Resident 30), reviewed for pressure ulcer, when the resident developed pressure injuries (Stage 1 on the right malleolus, Stage 2 on the right buttock, Stage 1 on the left upper buttock, Stage 3 on the left buttock and Stage 1 on the left posterior knee) and non-pressure injuries (open wound with yellowish dark brown discharge on the right foot 3rd, 4th, and 5th toes). […]

• Actual harm, isolatedF689Dec 30, 2025

  Based on observation, interview, and record review, the facility failed to maintain a safe environment and ensure adequate supervision was provided to prevent accidents for one of three residents reviewed (Resident 1), who was at risk for falls, self harm, and exhibited impulsive behavior, as indicated in the plan of care and facility policy.These failures resulted in Resident 1 having eight unwitnessed falls between July 2024 and December 2025. On May 13, 2025, Resident 1 sustained a hematoma (severe bruising with swelling) and a skin tear to her forehead. […]