Inspection Reports for
Meadowbrook Rehabilitation Hospital

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective July 21, 2016.

The inspection included complaint investigations #KS00090719 and #KS00100433.

The facility was found deficient in multiple areas including failure to assess, monitor and treat skin conditions for a cognitively impaired resident, failure to investigate and evaluate causes of multiple falls for a resident, failure to provide current education on pneumococcal immunizations, failure to dispose of expired medications, failure to maintain sanitary infection control procedures, and failure to ensure handrails were firmly and securely affixed in corridors.

The facility identified multiple deficiencies including incomplete skin assessments, inadequate fall investigations, lack of current education on Pneumococcal vaccine, improper disposal of expired medications, unsafe sanitary conditions, and unsecured handrails. The Plan of Correction details education, audits, and monitoring measures to address these issues.

The survey found the most serious deficiency to be at a 'D' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The report shows that deficiencies previously cited under regulations 483.25(a)(3) and 483.25(h) were corrected as of 08/14/2015.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety from July 23, 2015 through August 7, 2015 related to F323, CFR 483.25(h). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed effective September 1, 2015.

The complaint investigation found substantiated failures including inadequate bathing care and failure to prevent elopement of a resident who was found 0.8 miles from the facility after leaving unsupervised. Immediate jeopardy was identified and later abated.

The facility failed to provide adequate bathing for a cognitively impaired resident requiring total assistance and failed to provide effective interventions to prevent elopement of a resident at risk, who was found walking alone 0.8 miles from the facility. The resident eloped twice without timely staff response, exposing him/her to immediate jeopardy.

This plan of correction follows a complaint investigation survey exiting 08/10/2015. The facility asserts substantial compliance and outlines corrective actions to address the complaint deficiencies.

The facility had deficiencies related to activities of daily living care for dependent residents and ensuring a safe environment free of accident hazards, including supervision to prevent elopement. Corrective actions include updated bath schedules, staff re-education, elopement risk assessments, installation of security keypads and alarms, and ongoing monitoring and documentation.

The report documents that all previously cited deficiencies, identified by their regulation numbers and prefix codes, were corrected as of the revisit date.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The facility was found deficient in multiple areas including failure to notify residents prior to room changes, inaccurate and incomplete resident assessments, failure to update care plans timely, inadequate post-dialysis assessments, improper catheter care, fall prevention deficiencies, unsafe storage of hazardous chemicals, improper labeling of medications, failure to prevent infection transmission, and lack of physician participation in quality assurance meetings.

The Plan of Correction details multiple deficiencies related to residents' rights, comprehensive assessments, care planning, infection control, medication storage, fall prevention, and quality assurance processes. The facility commits to staff education, policy reviews, and ongoing monitoring to achieve substantial compliance by February 28, 2015.

The report confirms that all previously cited deficiencies identified by their regulation numbers and prefix codes have been corrected as of the revisit date.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was triggered by complaint investigations #79247 and #79372. The findings were substantiated as the facility failed in multiple regulatory requirements related to resident care and infection control.

The facility failed to complete timely Care Area Assessments and comprehensive care plans for sampled residents, failed to provide adequate pain management, failed to administer and document scheduled IV antibiotics, and failed to maintain infection control practices related to PICC line dressing changes.

This Plan of Correction is in response to deficiencies identified during a complaint investigation survey exiting on 9/25/2014.

The plan addresses multiple deficiencies including comprehensive assessments, care plan development, pain management, pharmaceutical services, and infection control. The facility outlines corrective actions such as staff education, audits, monitoring, and quality assurance meetings to ensure substantial compliance by 10/24/2014.

The report confirms that the previously identified deficiencies with ID prefixes S0600 and S1164 were corrected as of 2013-10-31.

The facility failed to have a Certified Dietary Manager for all on-site survey days and did not ensure the call light system functioned properly at the nurses' station annunciator panel for multiple days during the survey.

The revisit report shows that the previously cited deficiencies under regulations 483.13(c), 483.25(i), and 483.60(b),(d),(e) were corrected as of 07/09/2012.

The plan addresses deficiencies related to abuse prevention policy updates, follow-up on dietary recommendations, and medication labeling and expiration monitoring. Corrective actions include policy updates, staff education, audits, and ongoing compliance monitoring.

The facility failed to update its Abuse Prevention Policy to include timely reporting requirements, failed to maintain nutritional status for two residents with significant weight loss due to lack of implementation of dietary recommendations, and failed to properly label and date medications including insulin pens and multi-dose vials, retaining expired medications.