Meadowbrook Rehabilitation Hospital

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 16, 2025

  The facility identified a census of 109 residents. The sample included 22 residents, with two reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent avoidable accidents when direct care staff used the incorrect sling size while attempting to transfer Resident (R) 112, a quadriplegic (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord) resident with a history of traumatic brain injury. On 08/04/25 at 08:00 PM, Certified Nurse Aide (CNA) N and CNA O attempted to transfer R112 from her wheelchair to her bed, used the wrong sling size, the mechanical lift tipped over, and R112 fell to the floor from the lift's highest position. […]

• Immediate jeopardy, isolatedF689Mar 1, 2023

  The facility identified a census of 87 residents. The facility identified 16 residents at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) in the South building. The sample included four residents with three sampled for accidents. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. Resident (R) 1 was severely cognitively impaired and a high risk for elopement due to her dementia (progressive mental disorder characterized by failing memory, confusion). […]

• Immediate jeopardy, isolatedF689Jan 18, 2023

  The facility reported a census of 88 residents with 33 residents at the North campus. The sample included one resident reviewed for elopement (when a cognitively impaired resident exits the facility without staff knowledge or supervision). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R)1, who was cognitively impaired, at high risk for elopement, and at risk for falls due to an unsteady gait. On 01/01/23 at approximately 03:00 PM, R1 sat in the dining room with other residents. At 03:30 PM staff responded to the dining room door alarm. Staff observed R1's empty wheelchair next to the dining room door. Another resident in the area told staff R1 exited the facility through the dining room door. […]

• Immediate jeopardy, isolatedF742Dec 8, 2022

  The facility identified a census of 57 residents. The sample included four residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to acknowledge and implement a plan of care to address Resident (R) 1's personal history of trauma, increased depression, as well an actual suicide attempt. On [DATE] staff identified R1 in his room with a trash bag over his head in an effort to suffocate himself. R1 stated he wanted to die due to his decreased mobility and increased need for assistance. R1 was sent to the hospital for psychiatric treatment and returned to the facility on [DATE]. Upon return, the facility failed to initiate a plan of care, which addressed R1's recent actual suicide attempt or the causative factors. […]

• Actual harm, isolatedF600Nov 12, 2024

  The facility identified a census of 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, a cognitively impaired resident, remained free from staff-to-resident abuse. On 10/31/24, Certified Nurse Aide (CNA) M and CNA N got R1 ready for a shower. R1 started yelling and swatted at CNA M. CNA M swatted at R1 in return. After CNA M and CNA N got R1 up with the Hoyer lift (full body mechanical lift) and into the shower chair. R1 yelled loudly, and CNA M put her hand on R1's mouth and told R1 to hush. […]