Inspection Reports for
Meadowbrook Care Center

The inspection was complaint-driven, investigating multiple complaint numbers including OH00162453, OH00165072, OH00164179, OH00161596, OH00161253, OH00163155, OH00161596, OH00164317, OH00162543, and OH00165072.

The facility was found deficient in multiple areas including failure to follow up on resident council concerns, failure to notify physicians of significant weight loss, failure to maintain resident privacy, inadequate lighting and cleanliness, improper use of psychotropic medications, failure to provide bed hold notices, inaccurate Minimum Data Set assessments, incomplete care plans, failure to conduct quarterly care conferences, failure to reassess nutritional status after hospitalization, inadequate pressure ulcer care, improper tube feeding administration, unlabeled insulin pens, failure to serve proper food portions and therapeutic diets, improper food storage and handling, failure to follow infection control protocols, and failure to provide proper vaccine education and documentation.

The complaint involved an incident on 11/19/24 where Resident #4 was found undressed in Resident #41's bed. Staff statements and interviews revealed confusion and inconsistent observations. The facility did not notify the Director of Nursing or Administrator timely, did not initiate a Self-Reported Incident (SRI), and failed to conduct a formal investigation or issue formal findings. Resident #41 was placed on one-to-one supervision after the incident.

The facility failed to implement its abuse prevention policy when staff found two residents in a bed together, and failed to timely report and investigate the alleged abuse incident. Staff education was provided after the incident, but no formal investigation or report was completed.

No health deficiencies were found during the inspection.

The deficiencies represent noncompliance investigated under complaint number OH00154541 and also OH00154906 for medication administration and infection control issues.

The facility was found noncompliant in several areas: residents lacked access to call lights, wound care was not provided as ordered, pain medications were not administered timely, medication error rate exceeded 5%, and staff failed to wear appropriate PPE during high-contact care under Enhanced Barrier Precautions. These deficiencies affected multiple residents and represented minimal harm or potential for actual harm.

This deficiency represents non-compliance investigated under Complaint Number OH00152739 and Master Complaint Numbers OH00153494.

The facility failed to ensure proper pressure ulcer dressing changes per physician orders, proper colostomy care including hand hygiene during care, and timely attending physician visits every 60 days for residents. These deficiencies affected a few residents and represented non-compliance under multiple complaint numbers.

This deficiency represents non-compliance investigated under Master Complaint Number OH00148169. The facility was unaware that IV Company #700 was not licensed to dispense dangerous drugs in Ohio during the IV administrations from April 2023 to August 2023.

The facility failed to ensure that IV Company #700, which administered intravenous fluids to residents, was licensed by the Ohio State Pharmacy Board to dispense dangerous drugs. This affected 22 residents who received IV fluids from the unlicensed company. The facility was unaware of the lack of license during the period from April 2023 to August 2023.

The facility was found deficient in multiple areas including resident dignity and respect, advanced directive consistency, safe and homelike environment, care planning, activities of daily living assistance, incontinence care, administration of intravenous fluids by an unlicensed company, pharmaceutical services, laboratory services, dietary management, food safety and storage, antibiotic stewardship, and call light functionality in resident bathrooms.

This deficiency represents non-compliance investigated under Complaint Number OH00144009.

The facility failed to notify the resident's representative of two new unstageable pressure ulcers and failed to thoroughly assess and document the resident's skin condition following identification of an open area. The facility did not perform timely follow-up assessments or notify the representative as required by policy.

This deficiency represents non-compliance investigated under Complaint Numbers OH00139989, OH00140370, and OH00139989, with ongoing noncompliance from a prior survey dated 02/01/23.

The facility failed to ensure Resident #8 wore a sling as ordered by the physician, failed to appropriately monitor Resident #10's heart rate before Digoxin administration, and failed to maintain proper infection control practices with Resident #12's IV and wound vac, increasing risk of harm.

This deficiency represents non-compliance investigated under Complaint Number OH00139585.

The facility failed to monitor Resident #105's bowel movements over multiple days, resulting in severe fecal impaction and hospitalization. Documentation and physician notification were lacking despite care plan requirements and facility policy.

The facility failed to revise care plans for two residents (#33 and #102) when new conditions were identified, including contractures and an unstageable pressure ulcer, resulting in minimal harm or potential for actual harm to a few residents.