Meadowpark Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Meadowpark Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 20, 2023

  Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility neglected to maintain the physical safety of one resident (#1) out of 11 residents at risk for elopement regarding not providing services to prevent a resident with known exit-seeking behaviors and desire to leave the facility from falling down a flight of stairs and sustaining multiple life threatening injuries. […]

• Immediate jeopardy, isolatedF689Apr 20, 2023

  Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 11 residents at risk for elopement, was provided with supervision and services related to the resident's known exit-seeking behaviors and desire to exit the facility. The facility nursing staff failed to ensure the safety of Resident #1; on 4/13/2023 at approximately 1:15 PM, Resident #1 propelled herself in her wheelchair from the unit nurses' station, down the East Hall, passed by three staff offices, and approximately 141 feet to the East Hall emergency exit fire door. […]

• No harm, potential for more than minimal, patternF585Nov 21, 2024

  Based on observations, interviews, and record review, the facility failed to ensure the grievance process was conducted to resolve grievances in a timely manner for five residents (#3, #5, #6, #7, and #8) of eight sampled residents. Findings included: On 11/20/2024 at approximately 11:50 a.m., the NHA (Nursing Home Administrator) presented the facility grievance logs for 01/01/2024 through the date of survey, 11/20/2024. A review of the log revealed no information to identify the type of concern the grievance was about. The NHA was interviewed at 11:57 a.m. The NHA said she could not identify what kind of grievance was filed and she did not see a column to identify the type of grievance filed by the submitter. […]

• No harm, potential for more than minimal, patternF644Dec 7, 2023

  Based on record review, interview, and review of the facility's policy, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I for eight (Residents #50, #2, #69, #3, #22, #54, #65, and #56) of eight residents admitted with mental health and/or cognitive diagnoses sampled for PASRR. Findings include: 1. Review of the clinical record revealed Resident #50 was admitted to the facility on [DATE], with a primary diagnosis of multiple fractures according to the admission face sheet. […]

• No harm, potential for more than minimal, patternF656Dec 7, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement care plans for six (Residents #77, #313, #2, #50, #22, and #27) of twenty eight sampled residents. Finding included: 1. On [DATE] at 9:30 a.m., and 3:00 p.m., Resident #77 was observed in a room located at the end of the hallway. Resident was observed both times laying down in his bed with his call light not within his reach at 9:30 a.m., and within his reach at 3:00 p.m., his bed was observed in a low position. Resident # 77 was presented with no behaviors, pain, or discomfort. […]