4 Reports
Inspection Report — Jul 29, 2024
Complaint Investigation State
Date: Jul 29, 2024
Visit Reason
State-compiled facility profile showing 15 inspections from 2022 to 2024 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 98 complaints about this facility; 19 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 15 inspections, 11 had no citations while 4 resulted in 16 citations total, including 10 standard health and 6 life safety code violations. The facility had 98 complaints with 19 on-site inspections and one enforcement action with fines recorded.
Citations (16)
Standard Health Citation — quality of care: Encoding/transmitting Resident Assessments had a pattern of issues.
Standard Health Citation — quality of care: Facility Assessment was cited as an isolated issue.
Standard Health Citation — quality of care: Pharmacy services, procedures, pharmacist, and records had isolated deficiencies.
Standard Health Citation — quality of care: Resident Records - Identifiable Information had isolated issues.
Life Safety Code Citation — NFPA requirements: Sprinkler System maintenance and testing showed a pattern of problems.
Standard Health Citation — quality of care: Bowel/bladder Incontinence, Catheter, UTI issues were a pattern.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was an isolated deficiency.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation was an isolated issue.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was an isolated deficiency.
Life Safety Code Citation — NFPA requirements: Building Construction Type And Height had widespread issues.
Life Safety Code Citation — NFPA requirements: Hospital CAH And LTC Emergency Power had widespread problems.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General was an isolated issue.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was an isolated deficiency.
Life Safety Code Citation — NFPA requirements: Subsistence Needs For Staff And Patients had widespread deficiencies.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was widespread and not yet corrected (October 17, 2022).
Standard Health Citation — quality of care: Reporting - National Health Safety Network was widespread and not yet corrected (July 25, 2022).
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 16
Inspections with violations: 4
Inspections without violations: 11
Total complaints: 98
On-site complaint inspections: 19
Enforcement actions: 1
Total fines: 6000
Inspection Report — Jul 29, 2024
Annual Inspection CMS
Date: Jul 29, 2024
Visit Reason
The inspection was a Recertification survey conducted from 7/23/2024 to 7/29/2024 to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in timely electronic transmission of Minimum Data Set assessments, accurate maintenance of controlled drug records, accurate facility-wide resource assessment, and proper documentation of medical records including physician orders for oxygen therapy.
Citations (4)
Failure to ensure all completed Minimum Data Set (MDS) assessments were electronically transmitted to CMS within 14 days of completion, with delays of 16 to 132 days for three residents.
Failure to accurately maintain an account of all controlled drugs; discrepancy found in Oxycodone count for Resident #407 due to unrecorded administration.
Facility assessment inaccurately documented an excessive number of Certified Nurse Aides required during the day shift, later corrected from 57 to 39.
Failure to maintain complete and accurate medical records; Resident #452 received oxygen therapy without a current physician's order.
Report Facts
Days late for MDS transmission: 132
Days late for MDS transmission: 16
Days late for MDS transmission: 90
Certified Nurse Aides initially assessed: 57
Certified Nurse Aides revised assessment: 39
Oxycodone tablets discrepancy: 1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in medication administration error finding for failing to record Oxycodone administration | |
| Registered Nurse #4 | Nurse Educator | Interviewed regarding controlled drug record procedures |
| Director of Nursing Services | Interviewed regarding MDS transmission and controlled drug record procedures | |
| Minimum Data Set Coordinator #1 | Interviewed regarding failure to submit MDS assessments | |
| Administrator | Interviewed regarding Facility Assessment staffing numbers | |
| Licensed Practical Nurse #2 | Medication Nurse | Interviewed regarding oxygen therapy without physician order for Resident #452 |
| Registered Nurse #1 | Unit Manager | Interviewed regarding oxygen therapy order requirements |
Inspection Report — Nov 14, 2022
Annual Inspection CMS
Date: Nov 14, 2022
Visit Reason
The Recertification Survey was initiated on 11/7/2022 and completed on 11/14/2022 to assess compliance with regulatory requirements for Meadowbrook Care Center.
Findings
The facility was found deficient in timely reporting of abuse or neglect, thorough investigation of accidents, and development and implementation of comprehensive care plans. Specifically, Resident #61 had an unwitnessed fall resulting in a hip fracture that was not reported timely and care plans and nursing instructions were inconsistent regarding toileting assistance. Additionally, Resident #295 did not receive ordered Foley catheter care and flushing as documented in the Treatment Administration Records.
Citations (4)
Failure to timely report suspected abuse, neglect, or theft involving Resident #61's fall resulting in serious injury.
Failure to thoroughly investigate an accident involving Resident #61's fall and incomplete Accident and Incident report.
Failure to develop and implement a comprehensive person-centered care plan for Resident #61 including measurable objectives and timeframes, specifically regarding toileting assistance every 2-4 hours.
Failure to provide appropriate Foley catheter care and flushing for Resident #295 as ordered, with multiple undocumented occasions on the Treatment Administration Record.
Report Facts
Deficiencies cited: 4
Fall risk score: 8
Missed Foley catheter care occasions: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Documented Resident #61 fall and contacted physician for x-ray orders. |
| RN #6 | Risk Manager | Wrote conclusion on Accident and Incident report and interviewed regarding investigation. |
| DNS | Director of Nursing Services | Interviewed regarding reporting responsibilities and care plan communication. |
| CNA #1 | Certified Nursing Assistant | Assigned to Resident #61 during fall incident; interviewed about toileting assistance. |
| CNA #2 | Certified Nursing Assistant | Regularly scheduled CNA for Resident #61; interviewed about toileting needs. |
| CNA #3 | Certified Nursing Assistant | Regularly assigned CNA for Resident #61; interviewed about toileting assistance. |
| LPN #1 | Licensed Practical Nurse | Interviewed about CNA knowledge of Resident #61's care needs. |
| RN #3 | MDS Coordinator | Interviewed about MDS assessment and care instructions discrepancy. |
| RN #4 | MDS Coordinator | Interviewed about MDS assessment and care instructions discrepancy. |
| RN #5 | Unit Manager | Responsible for updating care plans and nursing instructions for Resident #61. |
| LPN #3 | Licensed Practical Nurse | Interviewed about providing Foley catheter care to Resident #295. |
| RN #7 | Registered Nurse Manager | Interviewed about providing and documenting Foley catheter care for Resident #295. |
| RN #9 | Registered Nurse | Interviewed about providing Foley catheter care and documentation for Resident #295. |
| LPN #6 | Licensed Practical Nurse | Interviewed about not providing Foley catheter care and not signing TAR for Resident #295. |
| Medical Director | Medical Director | Interviewed about importance of catheter care and documentation. |
Inspection Report — Jan 6, 2020
Annual Inspection CMS
Date: Jan 6, 2020
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including incomplete investigation of an accident/incident report related to a resident fall, failure to develop comprehensive care plans with measurable goals for dementia and respiratory care, inadequate implementation of a floor ambulation program, improper medication storage temperatures, and lapses in infection prevention and control practices.
Citations (5)
Failure to thoroughly investigate an Accident/Incident Report for Resident #81 with an unwitnessed hematoma and laceration to the forehead.
Did not develop a person-centered Comprehensive Care Plan (CCP) with measurable goals and timely updates for dementia care and respiratory care for Residents #207 and #97.
Did not ensure Resident #81 received the prescribed Floor Ambulation Program (FAP) of 200 feet; CCP and CNA assignments were not updated accordingly.
Medications including insulin were stored in a refrigerator at 30 degrees Fahrenheit, below the recommended 36-46 degrees Fahrenheit.
Infection prevention and control lapses observed: RN did not change gloves and wash hands during wound care for Resident #20; CNA placed a napkin that fell on the floor back on Resident #92's tray.
Report Facts
Deficiencies cited: 5
Floor Ambulation Program distance: 200
Floor Ambulation Program distance: 50
Medication refrigerator temperature: 30
Medication storage recommended temperature range: 36
Medication storage recommended temperature range: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager | Registered Nurse / Nurse Manager | Interviewed regarding Floor Ambulation Program and care plan updates for Resident #81 |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding Accident/Incident report investigation and infection control practices |
| Rehabilitation Registered Nurse | Rehabilitation Registered Nurse (RN) | Interviewed regarding Floor Ambulation Program implementation and care plan updates |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding initiation of Floor Ambulation Program orders |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding ambulation distances and infection control lapse with napkin placement |
| Director of Staff Development | Director of Staff Development (RN) | Interviewed regarding wound care competency and infection control expectations |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding infection prevention and control program compliance |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding proper medication storage temperatures |
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