Inspection Reports for
Meadowbrook Rehabilitation Hospital
427 W. MAIN STREET, GARDNER, KS, 66030-1183
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
88% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 109
Deficiencies: 14
Date: Sep 16, 2025
Visit Reason
Routine inspection of Meadowbrook Rehabilitation Hospital to assess compliance with healthcare regulations including resident care, medication management, and facility safety.
Findings
The facility had multiple deficiencies including failure to keep resident health information private, incomplete monitoring of psychotropic medication use, inadequate documentation of bed hold and transfer notifications, failure to complete significant change assessments, inconsistent monitoring of resident weights and fluid restrictions, improper pressure ulcer care, failure to maintain range of motion devices, unsafe mechanical lift use, incomplete pharmacist medication reviews, unsecured medication carts, and improper preparation of pureed diets.
Deficiencies (14)
F 0583: The facility failed to keep residents' protected health information private on medication carts left unlocked and unattended in common areas.
F 0605: The facility failed to ensure physician-ordered laboratory tests to monitor antipsychotic medications were completed and failed to document rationale for continued use without gradual dose reduction for two residents.
F 0628: The facility failed to provide required bed hold documentation and written transfer notifications to residents and their representatives upon hospital transfers.
F 0637: The facility failed to complete a Significant Change Minimum Data Set for a resident after discontinuance of hospice services.
F 0684: The facility failed to consistently follow physician orders for daily weight monitoring and fluid restriction for a resident with fluid overload.
F 0686: The facility failed to monitor a low-air-loss mattress for a resident and failed to provide a pressure-reducing device for another resident's wheelchair.
F 0688: The facility failed to ensure a resident received a prescribed hand splint to maintain range of motion and prevent contracture.
F 0689: The facility failed to prevent an accident when staff used the wrong size sling during a mechanical lift transfer, causing a resident to fall from the lift.
F 0726: The facility failed to verify and utilize the appropriate mechanical lift sling size for a resident, resulting in a non-injury fall from the lift.
F 0756: The facility failed to ensure consultant pharmacist recommendations were reviewed and addressed timely and failed to ensure physician-ordered laboratory tests were obtained for two residents.
F 0757: The facility failed to ensure physician-ordered laboratory tests were obtained for one resident and failed to consistently take and record blood pressures and pulse for another resident on beta blocker medication.
F 0761: The facility failed to secure medication carts containing insulin pens, needles, scheduled and over-the-counter medications, leaving them unlocked and unattended.
F 0804: The facility failed to follow nutritionally approved recipes during preparation of pureed meals, lacking fluid measurements and serving sizes to maintain nutritional value.
F 0851: The facility failed to submit complete and accurate direct care staffing information through Payroll-Based Journal (PBJ) as required, showing excessively low weekend staffing.
Report Facts
Residents affected: 109
Sample residents reviewed: 22
Deficiencies cited: 14
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged staff-to-resident abuse involving Resident 1 (R1) on 10/31/2024.
Complaint Details
The complaint investigation substantiated that CNA M was abusive to Resident 1 and another resident (R2) on 10/31/24. Witness statements confirmed CNA M swatted at R1 and put her hand over R1's mouth. The facility suspended CNA M immediately, notified law enforcement, and terminated CNA M on 11/07/24. The facility also failed to ensure immediate reporting of the abuse incident, as CNA N delayed reporting due to misunderstanding the reporting timeframe.
Findings
The facility failed to prevent staff-to-resident abuse by CNA M towards R1, resulting in impaired psychosocial well-being and risk for continued abuse. The facility also failed to ensure immediate reporting of the abuse incident, placing R1 at risk for further harm.
Deficiencies (2)
F 0600: The facility failed to protect Resident 1 from staff-to-resident abuse on 10/31/24 when CNA M put her hand over R1's mouth and swatted at her hand. This resulted in impaired psychosocial well-being and risk for continued abuse.
F 0609: The facility failed to ensure immediate reporting of suspected staff-to-resident abuse for Resident 1 on 10/31/24, placing the resident at risk for further abuse.
Report Facts
Resident census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse findings for swatting Resident 1 and putting her hand over the resident's mouth |
| CNA N | Certified Nurse Aide | Witnessed abuse by CNA M and reported the incident after a delay |
| Administrative Nurse E | Administrative Nurse | Assessed Resident 1 after the incident and participated in investigation |
| Administrative Nurse D | Administrative Nurse | Received abuse report and reported incident to Administrative Staff A |
| Administrative Staff A | Administrative Staff | Received abuse report and terminated CNA M |
Inspection Report
Routine
Census: 100
Deficiencies: 22
Date: Jan 25, 2024
Visit Reason
Routine inspection of Meadowbrook Rehabilitation Hospital to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, accommodate resident preferences, timely report and investigate injuries, provide adequate care plans, assist with activities of daily living, provide restorative therapy, implement fall prevention, manage medications properly, maintain food safety, and ensure proper immunization and equipment maintenance.
Deficiencies (22)
F 0550: The facility failed to promote and maintain dignity for Resident 28 by not covering his urinary catheter and staff discussed personal issues and used cell phones while assisting residents during dining.
F 0558: The facility failed to accommodate Resident 61's preferences by delivering meal trays with other residents' trays before her representative was present, risking impaired nutrition and quality of life.
F 0609: The facility failed to timely report Resident 96's black eye of unknown origin to the State Agency, risking further injury and unidentified abuse.
F 0610: The facility failed to thoroughly investigate Resident 96's injury of unknown origin, lacking witness statements and adequate follow-up.
F 0623: The facility failed to notify the State Long Term Care Ombudsman of Resident 76's facility-initiated discharge, risking impaired rights and advocate involvement.
F 0625: The facility failed to provide Resident 76 or her representative with a bed hold notice upon hospital discharge, risking impaired rights.
F 0656: The facility failed to develop a care plan for Resident 96's tremors, risking unmet care needs.
F 0657: The facility failed to revise care plans for Resident 18 with falls and Resident 61 no longer requiring enhanced barrier precautions, risking further injury and unmet care needs.
F 0677: The facility failed to provide adequate activities of daily living care and assistance to Residents 28, 38, 18, and 61, risking poor hygiene and impaired dignity.
F 0688: The facility failed to provide restorative therapy as planned for Resident 61, risking decline in mobility and function.
F 0689: The facility failed to implement fall prevention interventions for Resident 18 and failed to provide padded bed rails for Resident 96, risking injury.
F 0693: The facility failed to provide physician-ordered residual checks and water flushes for Resident 14's feeding tube, risking aspiration and inadequate hydration.
F 0726: The facility failed to complete competency assessments for staff, risking impaired care and decreased quality of life for residents using mechanical lifts.
F 0730: The facility failed to ensure certified nurse aides received 12 hours of annual in-service training, risking inadequate care.
F 0732: The facility failed to post nursing staffing information daily in each building as required.
F 0756: The Consultant Pharmacist failed to identify and report Resident 18's blood pressures outside physician-ordered parameters, risking unnecessary medication side effects.
F 0757: The facility failed to hold metoprolol for Resident 18 when blood pressures were out of parameters, risking physical decline and medication complications.
F 0758: The facility failed to obtain a physician rationale and risk versus benefit explanation for continued use of risperidone for Resident 31, risking unnecessary antipsychotic drug use.
F 0761: The facility failed to discard expired Pneumovax vaccination vials in the medication room, risking ineffective medications.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the south kitchen, risking foodborne illness.
F 0883: The facility failed to offer pneumococcal PCV20 vaccinations per CDC recommendations, risking residents' exposure to pneumococcal disease.
F 0908: The facility failed to maintain the south kitchen plate warmer in safe and operable condition, risking residents receiving cold food.
Report Facts
Residents affected: 100
Sample residents: 20
Medication doses given out of parameter: 15
Expired medication vials: 2
Uncovered catheter bag observations: 3
Residents in dining room during staff misconduct: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified catheter bag should be covered, confirmed staff should not discuss personal issues during meals, stated staff should hold blood pressure medication when out of parameters, verified lack of care plans and investigations |
| Certified Nurse Aide O | Certified Nurse Aide | Reported Resident 69 had tremors and staff tried to put arm sleeves on her |
| Certified Nurse Aide N | Certified Nurse Aide | Provided peri-care and barrier cream for Resident 18, assisted with transfers |
| Licensed Nurse H | Licensed Nurse | Obtained blood pressure and administered medications for Resident 18, stated staff held medication if blood pressure out of parameters |
| Certified Dietary Manager BB | Certified Dietary Manager | Verified food safety violations and kitchen maintenance issues |
| Administrative Nurse E | Administrative Nurse | Verified Resident 61's representative usually assisted with meals, confirmed lack of pneumococcal vaccination system |
| Administrative Staff C | Administrative Staff | Verified nursing staffing was not posted daily |
| Maintenance Staff U | Maintenance Staff | Unaware of kitchen equipment issues until notified |
Inspection Report
Routine
Census: 100
Deficiencies: 22
Date: Jan 25, 2024
Visit Reason
Routine inspection of Meadowbrook Rehabilitation Hospital to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, accommodate resident preferences, timely report and investigate injuries, notify ombudsman of discharges, develop and revise care plans, provide adequate activities of daily living assistance, provide restorative therapy, implement fall prevention interventions, ensure medication safety and monitoring, maintain food safety standards, provide vaccinations per CDC guidelines, maintain equipment, and ensure staff competency and training.
Deficiencies (22)
F 0550: The facility failed to promote and maintain dignity for Resident 28 by not covering his urinary catheter and staff discussed personal issues and used cell phones while assisting residents during dining.
F 0558: The facility failed to accommodate Resident 61's preferences by delivering meal trays with other residents' trays despite the representative not being present to assist, risking impaired nutrition and quality of life.
F 0609: The facility failed to timely report Resident 96's black eye of unknown origin to the State Agency, risking further injury and unidentified abuse.
F 0610: The facility failed to thoroughly investigate Resident 96's injury of unknown origin, lacking witness statements and interventions to prevent injury related to tremors.
F 0623: The facility failed to notify the State Long Term Care Ombudsman of Resident 76's facility-initiated discharge, risking impaired rights and advocate involvement.
F 0625: The facility failed to provide Resident 76 or representative a bed hold notice upon hospital discharge, risking impaired rights.
F 0656: The facility failed to develop a care plan for Resident 96's tremors, risking unmet care needs.
F 0657: The facility failed to revise care plans for Resident 18 after falls and Resident 61 after removal of enhanced barrier precautions, risking further injury and unmet care needs.
F 0677: The facility failed to provide adequate activities of daily living care for Residents 28, 38, 18, and 61, resulting in poor hygiene, soiled clothing, and unmet ADL needs.
F 0688: The facility failed to provide restorative therapy as planned for Resident 61, risking decline in mobility and function.
F 0689: The facility failed to implement fall prevention interventions for Resident 18 and failed to provide padded bed rails for Resident 96, risking injury.
F 0693: The facility failed to provide physician-ordered residual checks and water flushes for Resident 14's feeding tube, risking aspiration and inadequate hydration.
F 0726: The facility failed to complete competency assessments for staff, including licensed nurses and CNAs, risking impaired care and decreased quality of life.
F 0730: The facility failed to ensure certified nurse aides received 12 hours of annual in-service training, risking inadequate care.
F 0732: The facility failed to post nursing staffing information daily in each building as required.
F 0756: The facility failed to identify and report Resident 18's blood pressures outside physician-ordered parameters during medication regimen review, risking unnecessary medication side effects.
F 0757: The facility failed to hold metoprolol when Resident 18's blood pressures were out of parameters, risking physical decline and medication complications.
F 0758: The facility failed to obtain physician rationale and risk versus benefit explanation for continued use of risperidone for Resident 31, risking unnecessary antipsychotic drug use.
F 0761: The facility failed to discard expired Pneumovax vaccine vials in the medication room, risking ineffective medications.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the south kitchen, including uncovered, unlabeled, and undated food items and unsanitary conditions, risking foodborne illness.
F 0883: The facility failed to offer pneumococcal PCV20 vaccinations per CDC recommendations to residents, risking pneumococcal disease complications.
F 0908: The facility failed to maintain the south kitchen plate warmer in safe and operable condition, risking residents receiving cold food.
Report Facts
Deficiencies cited: 22
Resident census: 100
Sample size: 20
Feeding tube flush volume: 90
Feeding tube flush volume: 30
Metoprolol dose: 12.5
Blood pressure parameter: 110
Heart rate parameter: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including dignity, care plans, medication issues, and staff training |
| Certified Nurse Aide N | Certified Nurse Aide | Observed failure to reposition Resident 18 and provided peri-care |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on Resident 69's tremors and bruising prevention |
| Certified Medication Aide R | Certified Medication Aide | Reported lack of competency checks and Resident 38's bathing refusal |
| Licensed Nurse H | Licensed Nurse | Administered medications and commented on care for Residents 18 and 61 |
| Licensed Nurse J | Licensed Nurse | Observed feeding tube care for Resident 14 |
| Licensed Nurse L | Licensed Nurse | Observed feeding tube care and bathing issues |
| Licensed Nurse G | Licensed Nurse | Discussed Resident 96's injury and investigation |
| Certified Dietary Manager BB | Certified Dietary Manager | Verified food safety and kitchen sanitation issues |
| Maintenance Staff U | Maintenance Staff | Reported on kitchen maintenance issues and plate warmer |
| Administrative Nurse E | Administrative Nurse | Verified Resident 61 meal assistance and vaccination issues |
| Administrative Nurse F | Administrative Nurse | Verified Resident 38 bathing issues |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident where a cognitively impaired resident (R1) eloped by climbing out of a window and walking approximately one mile to a local drug store.
Complaint Details
The complaint investigation was substantiated. Resident R1, severely cognitively impaired and at high risk for elopement, exited the facility through an unsecured window on 02/17/23, walked approximately one mile to a local drug store, and was returned by law enforcement. The facility failed to secure windows and adequately supervise residents at risk.
Findings
The facility failed to identify and secure likely avenues of exit, including windows, allowing a high-risk resident to elope. Resident R1 exited through an unsecured window, exposing her to immediate jeopardy due to environmental hazards and cold weather.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, windows were unsecured allowing a high-risk resident to elope through a window.
Report Facts
Resident census: 87
Residents at risk for elopement: 16
Wandering/Elopement Risk Scale score: 12
Temperature: 37
Distance walked by resident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Attempted to administer medications to R1 prior to elopement | |
| Certified Nurse Aide (CNA) N | Provided witness statement about R1's behavior before elopement | |
| Certified Nurse Aide (CNA) M | Provided witness statement about R1's behavior and last seen before elopement | |
| Licensed Nurse (LN) G | Reported police arrival with R1 and staff response | |
| Administrative Nurse D | Verified camera footage and described staff actions post-elopement | |
| Administrative Staff A | Reported on securing windows and staff education after elopement | |
| Certified Nurse Aide (CNA) O | Described monitoring procedures for elopement risk residents | |
| Licensed Nurse (LN) H | Described procedures following elopement incidents |
Inspection Report
Routine
Census: 39
Deficiencies: 9
Date: Mar 16, 2022
Visit Reason
Routine inspection of Meadowbrook Rehabilitation Hospital to assess compliance with healthcare regulations and standards.
Findings
The facility failed to maintain adequate urostomy supplies for a resident, ensure accurate medication assessments and care plans, provide necessary bathing and range of motion care, maintain proper medication documentation, uphold food safety standards, and implement infection control precautions for residents with MRSA.
Deficiencies (9)
F 0558: The facility failed to provide care and services related to Resident 16's urostomy supplies being unavailable for six days, placing the resident at risk for physical discomfort and negative psychosocial impact.
F 0641: The facility failed to ensure accurate assessment and documentation of antipsychotic drug usage for Resident 27, risking miscommunication in care planning.
F 0657: The facility failed to revise Resident 27's comprehensive care plan to include psychotropic medication use and antibiotic therapy for aspiration pneumonia upon hospital readmission, risking adverse consequences.
F 0677: The facility failed to ensure bathing was provided for Resident 27 who required extensive assistance, risking skin breakdown and complications.
F 0688: The facility failed to apply ordered braces and splints for Resident 40, risking further decline in range of motion.
F 0756: The facility failed to ensure the physician documented a clinical indication for antipsychotic medication for Resident 27 as recommended by the consultant pharmacist, risking unnecessary medication administration.
F 0758: The facility failed to ensure an appropriate diagnosis for antipsychotic medication for Resident 27, risking unnecessary psychotropic medication administration.
F 0812: The facility failed to perform required cooking equipment checks, store food in a sanitary manner, and ensure kitchen appliances were wiped down daily, placing residents at risk of foodborne illness.
F 0880: The facility failed to identify and implement transmission-based precautions and personal protective equipment for Residents 22 and 23 with MRSA, placing residents at risk for infectious complications.
Report Facts
Residents Affected: 39
Sampled Residents: 12
Dishwasher sanitation log missing entries: 24
Walk-in refrigerator missing temperature checks: 24
Walk-in freezer missing temperature checks: 21
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jul 21, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25, 483.25(h), 483.25(n), 483.60(b),(d),(e), 483.65, and 483.70(h)(3) were corrected as of the revisit date.
Deficiencies (6)
Regulation 483.25 deficiency was corrected by the revisit date.
Regulation 483.25(h) deficiency was corrected by the revisit date.
Regulation 483.25(n) deficiency was corrected by the revisit date.
Regulation 483.60(b), (d), (e) deficiency was corrected by the revisit date.
Regulation 483.65 deficiency was corrected by the revisit date.
Regulation 483.70(h)(3) deficiency was corrected by the revisit date.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Date: Jul 13, 2016
Visit Reason
The inspection was conducted as a Health Survey and Complaint Investigations #KS00090719 and #KS00100433.
Complaint Details
The inspection included complaint investigations #KS00090719 and #KS00100433.
Findings
The facility failed to assess, monitor, and treat skin conditions for a cognitively impaired resident, failed to investigate and evaluate causes of multiple falls for another resident, failed to provide current education on pneumococcal immunizations, failed to dispose of expired medications, failed to maintain sanitary infection control procedures, and failed to ensure handrails were firmly affixed in corridors.
Deficiencies (6)
F309: The facility failed to routinely assess, monitor, and treat a cognitively impaired resident's skin condition, including lack of documentation and missed weekly skin assessments.
F323: The facility failed to identify and evaluate causative factors of multiple falls for a cognitively impaired resident and did not complete a fall investigation report for one fall.
F334: The facility failed to provide residents with current education regarding the benefits and potential side effects of the pneumococcal vaccine, using outdated information sheets.
F431: The facility failed to dispose of expired medications found in a medication cart, including Promethazine and Ondansetron expired since April 2016.
F441: The facility failed to follow sanitary infection control procedures, including inadequate disinfectant contact time and improper transport of linens.
F468: The facility failed to ensure handrails were firmly and securely affixed in corridors, with loose handrails observed in multiple resident care areas.
Report Facts
Resident census: 33
Sample size: 21
Expired medications: 5
Disinfectant contact time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct care staff | Interviewed regarding skin assessments and lotion application for resident #48. |
| Staff P | Direct care staff | Interviewed about resident #48's skin picking and documentation. |
| Staff I | Licensed staff | Interviewed about resident #48's rash treatment and fall assessments. |
| Staff D | Administrative nursing staff | Confirmed failure to assess and monitor resident #48's rash and discussed fall documentation expectations. |
| Staff Q | Direct care staff | Interviewed about care plan updates after resident falls. |
| Staff J | Direct care staff | Described resident #81's impulsive behavior and need for redirection. |
| Staff H | Licensed staff | Confirmed expired medications found in medication cart. |
| Staff AA | Housekeeping staff | Observed cleaning with improper disinfectant contact time and interviewed about disinfectant use. |
| Staff Z | Housekeeping staff | Interviewed about linen transport and disinfectant requirements. |
| Staff Y | Maintenance staff | Confirmed loose handrails and repairs needed. |
| Staff X | Administrative maintenance staff | Confirmed loose handrails in neighborhood 2. |
| Staff F | Administrative nursing staff | Interviewed about pneumococcal vaccine education materials. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 13, 2016
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to skin assessments, fall investigations, pneumococcal vaccine education, medication disposal, infection control, and maintenance of handrails. The Plan of Correction outlines corrective actions, staff education, and monitoring procedures to ensure compliance.
Deficiencies (6)
F309-D: The facility failed to complete skin assessments upon admission, weekly, and after falls, and to update care plans accordingly. Resident #48 had non-pressure related skin conditions that were not properly assessed or documented.
F323-D: The facility failed to ensure a safe environment and adequate supervision to prevent accidents, including thorough fall investigations. Resident #81 was no longer at the facility.
F334-C: The facility failed to provide residents with current education on the benefits and potential side effects of the Pneumococcal vaccine.
F431-D: The facility failed to properly dispose of expired medications, as identified in an audit of medication carts on 7/13/2016.
F441-F: The facility failed to maintain a safe, sanitary, and comfortable environment to prevent disease transmission, including staff knowledge of chemical kill times and proper linen handling.
F468-E: The facility failed to ensure all handrails were firmly affixed and secured in corridors of the 100 and 200 hallways.
Report Facts
Audit date: Jul 13, 2016
Plan of Correction completion date: Jul 21, 2016
Plan of Correction final review date: Aug 1, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 13, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated the acceptance of the plan of correction. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 31, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
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 a plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited for deficiencies resulting in a 'D' level severity, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: May 1, 2016
Provider agreement termination date: Jul 31, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 6, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that deficiencies previously reported under regulations 483.25(a)(3) and 483.25(h) were corrected by 08/14/2015.
Deficiencies (2)
Regulation 483.25(a)(3): Previously cited deficiency was corrected by 08/14/2015.
Regulation 483.25(h): Previously cited deficiency was corrected by 08/14/2015.
Report Facts
Correction completion date: Aug 14, 2015
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Aug 10, 2015
Visit Reason
The inspection was conducted as a partial extended complaint investigation triggered by complaints regarding inadequate bathing and failure to prevent resident elopement.
Complaint Details
The complaint investigation substantiated failures in bathing care and supervision to prevent elopement. Immediate jeopardy was identified due to the resident's elopement and exposure to danger. The immediate jeopardy was abated on 2015-08-07 after corrective actions including risk assessments, staff in-service, policy revisions, and physical security enhancements.
Findings
The facility failed to provide adequate bathing for a cognitively impaired resident requiring total assistance and failed to provide effective supervision to prevent elopement of a resident at risk, who left the facility twice without staff knowledge, including walking 0.8 miles away across a busy highway.
Deficiencies (2)
F 312: The facility failed to provide adequate bathing for a resident requiring extensive assistance, with lack of documentation of offered baths or refusals.
F 323: The facility failed to provide adequate supervision and interventions to prevent elopement of a resident at risk, resulting in the resident leaving the facility twice and walking 0.8 miles away unsupervised.
Report Facts
Resident census: 33
Distance resident eloped: 0.8
Speed limit: 45
Bathing frequency: 2
BIMS score: 12
Elopement incidents: 2
Response time: 15
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 10, 2015
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies identified during a complaint-related survey exiting on 2015-08-10.
Complaint Details
This Plan of Correction responds to deficiencies identified during a complaint investigation survey exiting on 2015-08-10.
Findings
The facility addressed deficiencies related to activities of daily living care for dependent residents and ensuring a safe environment free of accident hazards with adequate supervision. Corrective actions include updated bathing schedules, staff re-education, elopement risk assessments, installation of security keypads and alarms, and ongoing monitoring and reporting procedures.
Deficiencies (2)
F312 SS=D ADL care provided for dependent residents was deficient as resident number 2's bath schedule and care plan required updating to ensure timely personal hygiene. The facility implemented re-education and monitoring to ensure baths are completed at least twice weekly.
F323 SS=J The facility failed to maintain a resident environment free of accident hazards and adequate supervision to prevent accidents. Measures including continuous observation for resident number 1, elopement risk assessments, and enhanced security controls were implemented.
Report Facts
Complete Date for Plan of Correction: Aug 14, 2015
Date of survey exit: Aug 10, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 10, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance with participation requirements and was cited for 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 admissions were imposed.
Deficiencies (1)
F323, CFR 483.25(h) was cited for substandard quality of care constituting immediate jeopardy to resident health or safety from July 23, 2015 through August 7, 2015.
Report Facts
Denial of Payment for New Admissions Effective Date: Denial effective September 1, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 28, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited in the original survey were corrected as of the revisit date. The report lists multiple regulation numbers with correction completion dates of 02/28/2015.
Report Facts
Correction completion dates: 10
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 30, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility is found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'E' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 10
Date: Jan 30, 2015
Visit Reason
Annual health licensure resurvey of Meadowbrook Rehabilitation Hospital LTCU to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify residents of room changes, incomplete and inaccurate resident assessments, failure to update care plans timely, inadequate dialysis assessments, improper catheter care, failure to prevent resident falls and maintain a safe environment, improper medication labeling, failure to prevent infection spread, and lack of physician participation in quality assurance meetings.
Deficiencies (10)
F247: The facility failed to notify a resident or representative prior to a room change and failed to document the transfer in the medical record.
F272: The facility failed to complete accurate Care Area Assessments and Minimum Data Set assessments for residents with significant changes in condition.
F278: The facility failed to accurately reflect resident status in assessments, including infection and incontinence coding.
F280: The facility failed to update care plans timely to reflect changes in resident care needs.
F309: The facility failed to assess a resident's condition properly following dialysis treatments.
F315: The facility failed to provide appropriate catheter care, including preventing catheter tubing from dragging on the floor.
F323: The facility failed to prevent falls and maintain a safe environment free of hazardous chemicals for cognitively impaired residents.
F431: The facility failed to label and date opened medications and dressings in treatment carts.
F441: The facility failed to prevent exposure of a resident to MRSA by not prescreening before room transfer and lacked a policy to prevent cross contamination.
F520: The facility failed to have a physician participate at least quarterly in the Quality Assessment and Assurance meetings.
Report Facts
Resident census: 31
Sample size: 18
Fall risk score: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jan 30, 2015
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies identified during a survey conducted on January 30, 2015.
Findings
The Plan of Correction outlines corrective actions taken to address deficiencies related to residents' rights to notice before room changes, comprehensive assessments, care plan accuracy, infection control, medication storage, fall prevention, and quality assurance processes. The facility asserts substantial compliance with regulations upon re-survey.
Deficiencies (10)
F-247 SS=D RIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE. Nursing and social service staff will provide advance notice for room changes unless medically necessary, inform families and roommates, and document all notices in medical records.
F-272 SS=D COMPREHENSIVE ASSESSMENTS. Modifications were made to comprehensive assessments for accuracy, with ongoing review of all Care Area Assessments by nursing leadership.
F-278 SS=D ASSESSMENT/ACCURACY/COORDINATION/CERTIFIED. Significant changes were opened on residents' records and status changes will be reviewed to update MDS as needed.
F-280 SS=D RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP. Care plans were updated to reflect changes in resident conditions and medication, with daily and weekly reviews to ensure accuracy.
F-309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING. Post-dialysis assessments and communication forms were implemented to ensure adequate monitoring and communication for residents receiving dialysis.
F-315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER. Education and interventions were provided to prevent catheter tubing from dragging on the floor to reduce infection risk.
F-323 SS=E FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES. Alarm systems are used for precautions; staff education on fall prevention and root cause analysis of falls is ongoing.
F-431 SS=D DRUG RECORDS, LABEL/STOREDRUGS&BIOLOGICALS. Identified medication and dressing were removed; staff educated on proper labeling and medication storage policies.
F-441 SS=E INFECTION CONTROL, PREVENT SPREAD, LINENS. Protocols for infection control and resident relocation due to communicable diseases were reinforced with staff education.
F-520 SS=C CQAA COMMITTEE-MEMBERS/MEETQUARTERLY/PLANS. Quality Assurance/CQI meetings are held monthly with required attendance by Medical Directors and documentation of attendance.
Report Facts
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jon Scott | CEO/Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 24, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the Plan of Correction.
Findings
The report confirms that all previously identified deficiencies were corrected by the revisit date of 10/24/2014.
Deficiencies (5)
Regulation 483.20(b)(1): Previously cited deficiency corrected as of 10/24/2014.
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiency corrected as of 10/24/2014.
Regulation 483.25: Previously cited deficiency corrected as of 10/24/2014.
Regulation 483.60(a),(b): Previously cited deficiency corrected as of 10/24/2014.
Regulation 483.65: Previously cited deficiency corrected as of 10/24/2014.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 25, 2014
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies identified during a survey conducted on 2014-09-25.
Complaint Details
This Plan of Correction is in response to a complaint survey conducted on 2014-09-25.
Findings
The Plan of Correction outlines corrective actions taken to address deficiencies related to comprehensive assessments, care plans, pain management, pharmaceutical services, and infection control. The facility commits to ongoing monitoring and education to ensure substantial compliance by 2014-10-24.
Deficiencies (5)
F272 Comprehensive Assessments SS=D: The MDS/Care Plan Coordinator completed Care Area Assessments for affected residents and assigned an assistant to ensure timely updates per regulatory guidelines.
F279 Develop Comprehensive Care Plans SS=D: Care plans were updated to reflect current resident status, with ongoing monitoring and staff education to maintain accuracy.
F309 Provide Care/Services for Highest Well Being SS=D: Pain assessment procedures were revised to twice daily assessments with documentation and follow-up, supported by staff education and audits.
F425 Pharmaceutical SVC-Accurate Procedures, RPH SS=D: Pharmacy reconciliation was completed and nursing staff were re-educated on medication documentation with ongoing audits and disciplinary measures for noncompliance.
F441 Infection Control, Prevent Spread, Linens SS=D: PICC line dressing change was corrected immediately after missed dressing, with staff re-education and weekly audits to ensure compliance.
Report Facts
Completion date: Oct 24, 2014
Audit duration: 8
MDS Coordinator assistant hours: 20
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Sep 25, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #79247 and #79372.
Complaint Details
The inspection was triggered by complaint investigations #79247 and #79372.
Findings
The facility failed to complete timely Care Area Assessments and comprehensive care plans for sampled residents, inadequately managed pain for one resident, failed to administer and document IV medications as ordered, and did not maintain infection control practices related to PICC line dressing changes.
Deficiencies (5)
F272: The facility failed to complete Care Area Assessments for 1 of 3 sampled residents, missing documentation and analysis 23 days after admission.
F279: The facility failed to develop comprehensive care plans for 2 of 3 sampled residents, lacking documentation related to PICC line and PEG tube care.
F309: The facility failed to provide adequate pain management for 1 of 3 sampled residents, with missing pain assessments and ineffective follow-up on pain medication effectiveness.
F425: The facility failed to administer and document scheduled IV antibiotic doses for 1 of 3 residents, missing 18 doses of medication.
F441: The facility failed to change the PICC line dressing as scheduled for 1 of 3 residents, increasing risk of infection.
Report Facts
Residents present: 37
Residents sampled: 3
Missed IV antibiotic doses: 18
Pain assessment missing shifts: 10
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 31, 2013
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at Meadowbrook Rehabilitation Hospital LTCU.
Findings
The report documents that previously identified deficiencies under regulations 28-39-158(a) and 26-40-303(h)(1)(a)(i)(ii)(iii)(iv) have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 31, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers F0160, F0246, F0254, F0278, F0279, and F0280 were corrected by the revisit date of 10/31/2013.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 2
Date: Oct 7, 2013
Visit Reason
The visit was a Health Resurvey to assess compliance with regulatory requirements following previous deficiencies.
Findings
The facility failed to have a Certified Dietary Manager for all on-site survey days and did not ensure the resident call light system functioned properly at the nurses' station for multiple days during the survey.
Deficiencies (2)
28-39-158(a) Dietary services. The facility failed to have a Certified Dietary Manager for 4 of 4 on-site survey days as required.
26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) Nursing facility support system. The facility failed to ensure the call light system functioned properly at the nurses' station for 3 of 4 survey days.
Report Facts
Census: 34
Survey days: 4
Days call light system failed: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 24, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.13(c), 483.25(i), and 483.60(b), (d), (e) were corrected by 07/09/2012.
Deficiencies (3)
Regulation 483.13(c): Previously cited deficiency was corrected by 07/09/2012.
Regulation 483.25(i): Previously cited deficiency was corrected by 07/09/2012.
Regulation 483.60(b), (d), (e): Previously cited deficiency was corrected by 07/09/2012.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 26, 2012
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehab in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to abuse prevention policy updates, follow-up on dietary recommendations, and medication labeling and expiration monitoring.
Deficiencies (3)
F226: The Abuse Prevention Policy was updated to require staff to report reasonable suspicion of a crime resulting in serious bodily injury immediately, or within 24 hours if no bodily injury occurs.
F325: An audit will be conducted to ensure all dietary recommendations from January 1, 2012, onward are followed up and implemented within 72 hours.
F431: An audit identified unlabeled and expired medications; staff education and ongoing audits for labeling and expiration monitoring will be implemented.
Report Facts
Date of medication audit: Jun 26, 2012
Plan of Correction completion date: Jul 9, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Leneave | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Date: Jun 20, 2012
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following previous deficiencies.
Findings
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, and failed to properly label and date medications including insulin pens and multi-dose vials.
Deficiencies (3)
483.13(c) The facility failed to provide an abuse prevention policy that directed staff on the two time limits for reporting reasonable suspicion of a crime.
483.25(i) The facility failed to maintain nutritional status for two residents with significant weight loss and did not implement dietary recommendations in a timely manner.
483.60(b), (d), (e) The facility failed to label insulin medications and multi-dose medication vials with an open date and retained expired medications in medication rooms and carts.
Report Facts
Resident census: 31
Resident census: 30
Resident sample size: 18
Weight loss: 7
Weight loss: 14
Weight loss percentage: 9.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Acknowledged deficiencies in abuse policy and nutritional supplement orders | |
| Dietary staff C | Provided information on RD recommendations and acknowledged weight loss | |
| Administrative dietary staff D | Discussed weight loss and follow-up on dietary recommendations | |
| Licensed nursing staff B | Interviewed regarding insulin pen expiration and labeling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: H046101 2 POC H9W011
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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