Inspection Reports for
Meadowbrook Healthcare
154 Prospect Avenue, Plattsburgh, NY, 12901
Back to Facility ProfileInspection Report — Oct 25, 2024
Annual Inspection
Citations: 13
Date: Oct 25, 2024
Visit Reason
Recertification and abbreviated survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident notification of condition changes, use of physical restraints, comprehensive care planning, activity provision, pressure ulcer care, respiratory care, nursing staffing levels, medication management, medication labeling and storage, food safety, and infection control practices.
Citations (13)
F 0580: The facility failed to notify resident representatives and physicians timely of changes in condition for 3 residents, including falls and medication changes.
F 0604: Resident #198 was restrained with a seat belt and alarms without proper consent, monitoring, or adherence to orders, causing distress and potential harm.
F 0656: The facility did not develop or implement comprehensive, measurable care plans for 5 residents, including failure to update plans after incidents or changes.
F 0657: Care plans for 4 residents were not reviewed or revised after assessments or changes in condition, including psychiatric consults and wandering interventions.
F 0679: Residents #104 and #119 did not consistently attend meaningful activities tailored to their needs, limiting their quality of life.
F 0686: Resident #50's pressure ulcers were not properly assessed, treated, or documented, and treatments were inconsistently administered.
F 0695: Resident #9 received oxygen without a physician order; Resident #122 had oxygen delivered by unlicensed personnel.
F 0725: Facility failed to maintain minimum certified nurse aide staffing levels on multiple units and shifts from 10/05/2024 to 10/20/2024.
F 0755: Facility failed to maintain a valid controlled substance license and destroyed narcotics without approval, but corrected the issue.
F 0759: Medication error rate was 38.24% during observed medication passes, including late administration and undocumented medication modifications.
F 0761: Medications and biologicals were not properly labeled with open or expiration dates; medication carts were left unattended and unlocked.
F 0812: Food service areas including main kitchen and resident kitchenettes were unclean with food debris, soiled refrigerators, and damaged equipment.
F 0880: Staff did not consistently follow infection control practices for COVID isolation, including improper use and removal of personal protective equipment.
Report Facts
Medication error rate: 38.24
Certified Nurse Aide staffing shortfall: 1
Resident census: 233
Resident census: 239
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nurse | Administered IV infusion with gravity for Resident #68; medication pass observation. |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, medication, infection control. |
| Nurse Educator #1 | Nurse Educator | Interviewed regarding medication administration training and competencies. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed delivering oxygen and interviewed about oxygen delivery practices. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed medication pass and insulin administration; interviewed about medication practices. |
| Director of Food Services #1 | Director of Food Services | Interviewed regarding cleaning of kitchenettes and food safety. |
| Director of Housekeeping #1 | Director of Housekeeping | Interviewed regarding cleaning responsibilities for kitchenettes. |
| Registered Nurse #3 | Nurse Manager | Interviewed regarding wound care and dialysis documentation. |
Inspection Report — Oct 25, 2024
Complaint Investigation
Citations: 19
Date: Oct 25, 2024
Visit Reason
State-compiled facility profile showing 2 inspections from 2022 to 2026 with citation and complaint history including enforcement actions.
Complaint Details
The state logged 74 complaints about this facility; 3 led to on-site inspections.
Findings
Across 2 inspections in the reporting period, 20 citations were issued including 15 standard health and 5 life safety code citations. The facility had 74 complaints with 3 on-site inspections and 1 enforcement action recorded.
Citations (19)
Standard Health Citation — quality of care: Activities did not meet interest or needs of each resident.
Standard Health Citation — quality of care: Care plan timing and revision deficiencies noted.
Standard Health Citation — quality of care: Failed to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Dialysis care issues identified.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were not sanitary.
Standard Health Citation — quality of care: Medication error rate exceeded 5 percent.
Standard Health Citation — quality of care: Infection control deficiencies found.
Standard Health Citation — quality of care: Infection prevention and control issues noted.
Standard Health Citation — quality of care: Labeling and storage of drugs and biologicals were inadequate.
Standard Health Citation — quality of care: Failure to notify of changes such as injury, decline, or room changes.
Standard Health Citation — quality of care: Pharmacy services, procedures, pharmacist involvement, and records were deficient.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were inadequate.
Standard Health Citation — quality of care: Residents' right to be free from physical restraints was violated.
Standard Health Citation — quality of care: Nursing staff levels were insufficient.
Standard Health Citation — quality of care: Treatment and services to prevent or heal pressure ulcers were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies found.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies found (duplicate).
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces smoke barrier issues noted.
Life Safety Code Citation — NFPA requirements: Vertical openings enclosure deficiencies identified.
Report Facts
Inspections on page: 2
Total violations/deficiencies cited: 20
Inspections with violations: 1
Inspections without violations: 1
Complaints total: 74
On-site complaint inspections: 3
Enforcement actions: 1
Total fines: 4000
Citations issued: 20
Inspection Report — Jul 30, 2021
Citations: 0
Date: Jul 30, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Meadowbrook Healthcare.
Findings
No health deficiencies were found during the survey.
Inspection Report — Feb 28, 2019
Annual Inspection
Citations: 11
Date: Feb 28, 2019
Visit Reason
Recertification survey and abbreviated survey to assess compliance with federal and state regulations for nursing home operations and resident care.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during meals, inadequate notification of hospital transfers and bed hold policies, incomplete comprehensive care plans, insufficient activity programming, lack of vision care plans, unsecured medications, extended meal intervals without resident agreement, lack of policy on food brought by visitors, missing carbon monoxide detectors, and lapses in infection control practices.
Citations (11)
F 0550: The facility did not ensure residents were treated with dignity during meals, including moving residents during meals, inconsistent meal service timing, and medication administration while residents were eating.
F 0623: The facility failed to provide timely written notification of hospital transfers/discharges and reasons to residents or their representatives for 4 of 5 residents reviewed.
F 0625: The facility did not provide written notice of bed hold policies to residents or their representatives for 4 of 5 residents reviewed for hospitalization.
F 0656: The facility failed to develop and implement comprehensive care plans addressing medical, nursing, mental, and psychosocial needs for 9 of 16 residents reviewed.
F 0679: The facility did not provide ongoing activities meeting residents' preferences and needs for 2 of 4 residents reviewed, with limited engagement and inadequate staffing.
F 0685: The facility did not assist a resident in gaining access to vision services or provide a care plan for vision impairment, resulting in missing glasses and impaired reading ability.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards by leaving medications unsecured and unattended at a resident's bedside.
F 0809: The facility did not ensure meals and snacks were served in accordance with resident needs and preferences, with an extended interval of over 14 hours between evening and breakfast meals without resident group agreement.
F 0813: The facility lacked a policy and education for families and visitors on safe preparation, handling, and storage of foods brought in for residents.
F 0836: The facility was not licensed and did not operate in compliance with applicable laws by failing to provide carbon monoxide detection near fuel burning appliances in the main kitchen.
F 0880: The facility failed to maintain an infection prevention and control program by not implementing droplet precautions for a resident with RSV and lapses in infection control during a dressing change.
Report Facts
Residents reviewed for hospitalization notification: 5
Residents reviewed for comprehensive care plans: 16
Residents reviewed for activities: 4
Residents reviewed for vision care: 5
Medication count administered at 8:00 AM: 12
Meal interval hours: 14.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in medication administration during meals finding |
| RN #14 | Registered Nurse | Named in meal service timing finding |
| CNA #3 | Certified Nursing Assistant | Named in dining room crowding and resident movement finding |
| CNA #16 | Certified Nursing Assistant | Named in dining room crowding and resident movement finding |
| CNA #4 | Certified Nursing Assistant | Named in meal service timing and resident agitation finding |
| RN #6 | Supervising Registered Nurse | Named in dining room crowding and meal service timing findings |
| Director of Social Work (SW) #2 | Director of Social Work | Named in hospital transfer notification and bed hold policy findings |
| Registered Nurse #12 | Registered Nurse | Named in comprehensive care plan development finding |
| Director of Nursing (DON) | Director of Nursing | Named in comprehensive care plan and vision care findings |
| CNA #1 | Certified Nursing Assistant | Named in communication deficit finding |
| LPN #4 | Licensed Practical Nurse | Named in medication left unsecured finding |
| Director of Engineering | Director of Engineering | Named in carbon monoxide detection finding |
| RN #3 | Registered Nurse / Infection Control Nurse / Assistant Director of Nursing | Named in infection control and droplet precautions finding |
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