Meadowbrook Village Christian Retirement Community

In the surveyor’s words

From the most serious findings on record at Meadowbrook Village Christian Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 30, 2023

  Based on interview and record reviews, the facility failed to implement a water system that included Legionella testing for thirteen out of thirteen residents affected. This failure had the potential of affecting the health and safety of residents in the facility. Findings: During an interview on 11/29/2023 at 2:46 P.M., with the Maintenance Supervisor (MS), MS stated that the facility used solar water heating. The MS stated water was heated up to 140 degrees Fahrenheit. The MS further stated he did not know of any policies and procedures on Legionella prevention, and it should be the Director of Nursing (DON) handling it under the infection control program. […]

• No harm, potential for more than minimal, patternF655Feb 13, 2026

  Based on observation, interview and record review, the facility failed to ensure a baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) meeting was conducted within 48 hours for one of two residents (Resident 21) reviewed for baseline care planning. This failure had the potential for incomplete and lack of care interventions for residents in the event of a serious change of condition to potentially occur to residents after admission. In addition, the lack of communication among facility staff and resident or responsible party had the potential to affect the quality of care to the resident. […]

• No harm, potential for more than minimal, patternF730Feb 13, 2026

  Based on interview and record review the facility failed to ensure employee performance evaluations were completed annually for four of five Certified Nurse Assistants (CNA) reviewed for performance reviews. This deficient practice had the potential for CNAs to provide inadequate care to the residents.Findings: A concurrent employee personnel record review and interview was conducted on 2/12/26 at 10:07 A.M. with the Director of Staff Development (DSD- a licensed nurse responsible for staff training). The DSD stated she had not completed CNA performance evaluations for the year 2025. CNA records were reviewed: CNA 5 was hired by the facility on 11/11/22 and no performance evaluation was completed for 2025. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2026

  Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: 1.Food stored in the refrigerators and freezer were expired and did not have a label, 2.Food stored in the dry storage room were expired or mislabeled, 3.Drying rack had scoopers stored in a container with debris and a green cutting board with discolored center had deep knife marks. 4.A stand electric fan with black debris on the blades was in the kitchen facing the food prep area. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2026

  Based on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1.Facility staff were unaware of the required Enhanced Barrier Precaution (EBP-an infection control strategy that mandate the use of gowns and gloves during high-contact resident care) for a resident (Resident 6) with an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine), 2. A stand electric fan with black debris on the blades was inside the kitchen food prep area. […]