Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook Rehabilitation Hospital during CMS and state inspections, most recent first.
A resident with quadriplegia, TBI, and severe cognitive impairment was transferred with a Hoyer lift using the wrong sling size. Two CNAs raised the resident in the lift, realized the sling was too big, and tried to reposition her while she was suspended above a wheelchair. The lift tilted and fell over, causing the resident to fall to the floor.
Unsecured medication carts were observed with insulin pens, needles, scheduled meds, and OTC meds inside. Four carts in a commons area were left unlocked, and another cart in an 800 hallway was also unsecured. An LN and CMAs later locked the carts. Staff stated medication carts should never be left unattended and that insulin pens and needles should be locked when not under direct observation.
Unsecured PHI Visible on Unattended Medication Carts: A medication cart with an open, unlocked laptop was left unattended in a hallway, displaying a resident’s medication, DOB, allergy information, and code status. Another observation found multiple medication carts in a commons area with an unlocked laptop showing the PHI of four residents while the LN and CMA walked away into the dining room. Staff later stated the cart should be locked and the screen closed, and that resident PHI should never be left visible.
A resident with quadriplegia, TBI, and severe cognitive impairment was transferred with a Hoyer lift using the wrong sling size. Staff attempted to reposition her while she was suspended, the sling became stuck on the wheelchair, and the lift tilted and fell with the resident to the floor. The resident had no injuries, and the investigation identified the incorrect sling as the root cause.
A facility failed to obtain ordered lab monitoring for two residents receiving psychotropic and other medications, with missing CBC, CMP, drug levels, and yearly labs documented in the EMR despite standing physician orders and care plans requiring lab collection. In a separate issue, a resident receiving carvedilol had multiple medication administrations recorded without documented BP and pulse checks even though the order included hold parameters. Staff interviews confirmed expectations that ordered labs and medication-related vitals should be obtained and documented.
Puree Diet Preparation Did Not Follow Approved Recipes: Dietary staff prepared pureed country fried steak, corn, and cake by adding broth, thickener, and milk without reviewing a recipe during the process. The facility’s pureed diet recipe lacked serving amounts and fluid measurements needed to maintain nutritional value, and an LPN stated the staff should have referenced the recipes.
A resident receiving antipsychotic therapy had ordered CBC, CMP, and Haldol level monitoring, but the EMR lacked lab results and the facility could not produce evidence that the Haldol levels were completed. Another resident with multiple psychotropic meds, including antipsychotics, had no documented GDR attempt and no physician rationale showing that a GDR was clinically contraindicated. Interviews with an LN and an administrative nurse showed the facility relied on portal entry and record download processes for lab tracking, while the care plans called for monthly med review and obtaining labs as ordered.
Failure to Provide Bed-Hold and Transfer Notices: The facility did not provide required bed-hold information and written transfer notices to residents and/or their representatives when residents were sent to the hospital. Staff reported confusion about whether nursing or social services was responsible, and the EMR bed-hold assessment was completed without obtaining a signed written notice. The affected residents had significant medical needs, including COPD, HF, DM, wounds, and dependence with ADLs, and one resident was transferred after worsening oxygen levels and breathing difficulty.
Failure to Complete Significant Change MDS After Hospice Discontinuation: A resident with multiple chronic conditions, severe cognitive impairment, and total ADL dependence had hospice services discontinued and was placed on palliative care, but the clinical record lacked evidence that the facility completed a comprehensive Significant Change MDS. The Administrative Nurse stated she was unaware that a Significant Change MDS was needed when a resident went off hospice or onto palliative care.
A resident with fluid overload, heart failure, renal insufficiency, and other chronic conditions had physician orders for daily weights and a 1500 ml fluid restriction, but weights were only documented 3 days per week and daily intake from meals was not documented. Staff described a process where CNAs weighed residents from a nurse-generated list, and an admin nurse stated the resident was not compliant with the fluid restriction. The resident was observed in bed asleep or with eyes shut during multiple observations.
Failure to monitor a low-air-loss mattress and provide a wheelchair cushion. One resident with severe cognitive impairment, multiple chronic conditions, and pressure injury risk had a low-air-loss mattress ordered to be checked every shift, but the mattress setting did not match the resident’s weight. Another resident with dementia, hemiparesis, and pressure injury risk was observed using a wheelchair without the care-planned pressure-reducing cushion, and staff confirmed the cushion was expected to be in place.
Failure to apply ordered right-hand splint: A resident with dementia, CVA, hemiparesis, and a right-hand contracture was observed propelling his wheelchair without the ordered splint in place. His right hand was tightly closed, and staff interviews confirmed the nurse was responsible for ensuring the brace or splint was applied and documented as ordered.
Failure to Complete Monthly Pharmacist Review and Track Ordered Labs: The facility did not ensure the CP’s monthly drug regimen reviews were documented, reviewed by the physician, and addressed for two residents receiving psychotropic and other medications. One resident had severe cognitive impairment and multiple diagnoses, while the other had intact cognition and psychiatric diagnoses. Ordered labs such as CBC, CMP, drug levels, and yearly vitamin/thyroid studies were missing from the EMR, and staff stated administrative nurses handled the MMRs and physician review.
Incomplete PBJ Staffing Submission: CMS PBJ reports for multiple quarters showed excessively low weekend staffing, even though a review of weekend and licensed nurse hours found appropriate coverage. An administrative staff member responsible for PBJ submissions said she used software to verify hours and had made changes related to removing ancillary staff from total hours, while stating the weekend licensed nurse staffing pattern remained the same. The facility’s PBJ policy required timely submission of complete and accurate direct care staffing data, including agency and contract staff, based on payroll and other verifiable records.
A cognitively impaired resident was subjected to staff-to-resident abuse by a CNA during a shower preparation. The resident, who has severe cognitive impairment and is dependent on staff for transfers, began yelling and swatting at the CNA, who responded by swatting back and placing her hand over the resident's mouth. This behavior was witnessed by another CNA, who reported the incident. The facility's investigation confirmed the abuse, with witness statements and an assessment supporting the claims. The incident resulted in impaired psychosocial well-being for the resident.
A resident with severe cognitive impairment and physical disabilities was subjected to abuse by a CNA during a shower. The CNA swatted at the resident and placed a hand over the resident's mouth to quiet her. Another CNA witnessed the incident but delayed reporting it, violating the facility's policy requiring immediate reporting of abuse. The delay in reporting placed the resident at risk for further harm.
Incorrect Sling Size During Mechanical Lift Transfer
Penalty
Summary
The facility failed to prevent an avoidable accident when two CNAs attempted to transfer a resident with quadriplegia, muscle weakness, traumatic brain injury, and severe cognitive impairment using a mechanical lift with the wrong sling size. The resident’s care plan required a Hoyer lift with two staff and a medium-sized sling for transfers to bed and chair, and the resident was dependent on staff for transfers and used a wheelchair for mobility. On the evening of the incident, the CNAs raised the resident in the lift and realized the sling was too big. While trying to reposition the resident, they could not get her to clear the wheelchair armrest. One CNA attempted to pull the wheelchair out while the other continued lifting, and the mechanical lift began to tilt while in its highest position. The lift and the resident fell to the floor during the transfer. The facility investigation concluded that staff used the wrong size sling for the transfer. Witness statements confirmed the resident was lifted too high, the sling became stuck on the wheelchair, and the staff attempted to maneuver the resident while she was suspended in the air. The resident was assessed with no injuries and sent to an acute medical facility for further evaluation.
Unsecured Medication Carts Containing Insulin and Medications
Penalty
Summary
The facility failed to secure medication carts containing residents’ insulin pens and needles, scheduled medications, and over-the-counter medications. During a walk-through on 09/14/25 at 09:05 AM, four medication carts in the commons area room were observed unlocked and unsecured, and the carts contained insulin pens, needles, residents’ scheduled medications, and over-the-counter medications. The Certified Medication Aides and a Licensed Nurse secured the carts, and LN J locked all of the medication carts. Later that same day at 09:15 AM, a medication cart in the 800 hallway was also observed unlocked and unsecured with scheduled medications and over-the-counter medications inside. The CMA secured that cart, and LN J locked it. On 09/16/25, LN G stated medication carts should never be left unattended and that insulin pens and needles should be locked in the cart when staff are not within eyesight. Administrative Nurse D stated medication carts should be locked and never left unattended, and that the facility expected medication carts to be locked with the keys kept by the nurse or CMA. The facility’s Medication Storage policy stated all drugs and biologicals must be stored in locked compartments and that medications must be under direct observation or locked in the medication storage area/cart during a medication pass.
Unsecured PHI Visible on Unattended Medication Carts
Penalty
Summary
The facility failed to keep residents’ protected health information private and confidential when medication carts with open laptop computers were left unattended in common areas. On 09/14/25 at 9:00 AM, a medication cart was observed parked in the 800 hallway with a laptop computer open on the cart and no Licensed Nurse or Certified Medication Aide present. The computer screen was unlocked and displayed R15’s medication information, date of birth, allergy information, and code status, visible to anyone passing by. LN J locked the screen. On 09/14/25 at 09:05 AM, four medication carts were observed parked in the commons room with a laptop computer open on one of the carts while the LN and CMA walked away into the dining room. The computer screen was left unlocked and displayed the PHI of R12, R80, R13, and R54, including medications, date of birth, allergy information, and code status, visible to anyone passing by. On 09/16/25, LN H stated the medication cart should be locked and the computer screen should be closed, and Administrative Nurse D stated she expected staff to close the computer screen before walking away from the medication cart and that residents’ PHI should never be left on the computer screen.
Incorrect Hoyer Sling Used During Transfer
Penalty
Summary
Direct care staff failed to verify and use the correct Hoyer lift sling when transferring a resident with quadriplegia, muscle weakness, and traumatic brain injury. The resident’s MDS showed a BIMS score of zero, indicating severe cognitive impairment, and she was dependent on staff for transfers, bathing, dressing, personal hygiene, bed mobility, and oral hygiene. Her care plan directed staff to use a Hoyer lift with two staff present for transfers and specified a medium-sized sling. During an attempted transfer from the resident’s wheelchair to her bed, staff used the wrong size sling. The investigation noted that the lift tilted and the resident and lift fell to the floor. The resident was assessed with no injuries and was sent to an acute medical facility for further assessment. The root-cause analysis identified that staff used the wrong size sling for the transfer. Witness statements described staff raising the resident in the Hoyer lift, discovering the sling was too big, and then attempting to reposition her while she remained lifted. Staff reported that the sling became stuck on the wheelchair, the resident could not clear the armrest, and the lift began to tilt as they tried to maneuver her around the chair. Facility staff stated that care plans should identify sling size, that staff were expected to verify sling size before transfers, and that staff should stop and get help if there were questions, but the transfer was still attempted with the incorrect sling.
Missed Lab Monitoring and Incomplete Vital Sign Checks for Medication Administration
Penalty
Summary
The facility failed to ensure physician-ordered laboratory tests were obtained as ordered for two residents receiving psychotropic and other medications. One resident had diagnoses including major depressive disorder, anxiety, epilepsy, CHF, and dementia, with a BIMS score of 7 indicating severely impaired cognition. His record showed standing orders for CBC, CMP, Vitamin B12, Vitamin D, Valproic Acid, and Keppra levels at specified intervals, but the EMR lacked results for CBC and CMP from May 2025 and August 2025, Keppra and Valproic Acid levels from April 2025 and July 2025, and yearly lab work. The resident’s care plan stated nursing staff would obtain lab work as ordered by the physician. A second resident had diagnoses including anxiety, paranoid schizophrenia, schizophrenia, and major depressive disorder, with a BIMS score of 15 indicating intact cognition. Her record showed physician orders for yearly Vitamin B12, Hemoglobin A1C, lipid panel, T4, TSH, and Vitamin D, as well as CBC, CMP, and Haldol levels every three months. The EMR lacked results for the yearly Vitamin B12, T4, TSH, and Vitamin D labs from April 2025 and lacked CBC and CMP results from March 2025. Her care plan also documented that nursing staff would obtain laboratory tests as ordered by the physician. Staff interviews showed the nurse who obtained the lab order was expected to enter it into the laboratory provider portal so it could be drawn as ordered, and administrative nursing staff stated medical records would help ensure the lab tests were obtained and results downloaded into the EMR. The facility’s Laboratory Services and Reporting policy stated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The report also identified a separate failure for a third resident receiving carvedilol: the TAR documented multiple medication passes without evidence that blood pressure was obtained before administration of the beta blocker, despite the order to hold for SBP less than 110 or HR less than 60. Staff stated vitals should always be obtained when a medication has parameters, and administrative nursing staff stated she was unsure why blood pressure and pulse were not obtained before the resident received the beta blocker.
Puree Diet Preparation Did Not Follow Approved Recipes
Penalty
Summary
The facility failed to follow nutritionally approved recipes during preparation of puree-textured meals for residents on a puree diet. The facility had a census of 109 residents, including six residents on a puree textured diet, and one resident received a double portion so seven pureed servings were prepared. During observation on 09/15/25 at 11:25 AM, Dietary Staff CC prepared cooked country fried steak by placing it in a food processor with one cup of beef broth, then added several spoons of thickener powder before checking the consistency and transferring it to a metal container. She then processed corn with one cup of chicken broth and several spoons of thickener powder, and later processed cake with about a cup of milk, adding more milk after checking the consistency. Dietary Staff CC did not review a recipe during the process. The facility provided a recipe for the pureed altered diet, but it lacked the indication of servings and the fluid measurement to be added to maintain the nutritional value for each serving of food. On 09/16/25 at 12:10 PM, Dietary Staff BB stated that Dietary Staff CC should reference the recipes and that the recipe should identify the servings with the measurement needed to maintain nutritional value. The facility's Therapeutic Diet Orders policy dated 03/26/25 stated that residents are to be provided foods in the appropriate form and/or nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team in accordance with goals and preferences.
Uncompleted antipsychotic lab monitoring and missing GDR rationale
Penalty
Summary
The facility failed to ensure ordered laboratory monitoring was completed for a resident receiving antipsychotic medication. The resident had diagnoses including anxiety, paranoid schizophrenia, schizophrenia, and major depressive disorder, and the Annual MDS documented a BIMS score of 15, indicating intact cognition. The resident’s record showed orders for CBC, CMP, and a Haldol level every three months, along with Haldol injection every 28 days for schizophrenia. However, the EMR lacked laboratory results, and the facility was unable to provide evidence of Haldol level results for March 2025 and June 2025. During interviews, a licensed nurse stated she entered the lab order into the laboratory portal as ordered by the physician, and an administrative nurse stated she expected the nurse who obtained the lab order to enter it into the laboratory provider portal to be drawn as ordered. The administrative nurse also stated the lab order could be entered as an ongoing order if that was what the physician had ordered, and that the physician could review the lab in the provider portal before results were downloaded into the resident’s EMR. The resident’s care plan documented that nursing staff would obtain laboratory tests as ordered by the physician, and the plan of care stated medications would be reviewed monthly by the physician and pharmacist. The facility also failed to ensure physician documentation supported the continued use of an antipsychotic medication for another resident without a gradual dose reduction. This resident had diagnoses including PTSD, anxiety, major depressive disorder, paranoid schizophrenia, schizophrenia, and Parkinson’s disease, and the Significant Change MDS documented a BIMS score of 12, indicating moderately impaired cognition. The MDS documented use of multiple psychotropic medications, including antipsychotic, antidepressant, antianxiety, anticonvulsant, hypoglycemic, opioid, and antiplatelet medications, and stated that a gradual dose reduction had not been attempted and that there was no physician documentation that a gradual dose reduction was clinically contraindicated. The resident’s record included orders for buspirone, olanzapine, Risperdal, trazodone, and Xanax, and the facility was unable to provide physician documentation that a gradual dose reduction was clinically contraindicated.
Failure to Provide Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided bed-hold information and written notification of transfer as required when residents were transferred to the hospital. The report identified this failure for three residents, including two residents who were transferred to the hospital and one resident who was transferred from the facility and later returned. Facility staff stated that the bed-hold assessment was completed in the EMR when a resident was sent out, but a written form was not obtained and the resident or representative did not sign a bed-hold notice. One resident had multiple chronic conditions including sleep apnea, venous insufficiency, edema, heart failure, DM, morbid obesity with alveolar hypoventilation, COPD, and encephalopathy. The resident’s MDS documented intact cognition, need for assistance with several ADLs, scheduled pain medication use, pain affecting therapy, sleep, and daily activities, and shortness of breath when lying flat with use of oxygen and a non-invasive ventilator. The resident was sent to the ED after oxygen levels were lower than usual and breathing became difficult, and the DON and a family member were notified of the transfer. The resident later returned to the facility from the hospital. Another resident had diagnoses including TIA, COPD, heart failure, and pulmonary embolism. The resident’s MDS documented intact cognition, dependence on staff for all ADLs, wheelchair use, and a goal to remain in the facility with active discharge planning to return to the community. The resident had an unplanned discharge to an acute hospital with return anticipated and then re-entered the facility from the hospital. The facility failed to provide the resident and/or representative with the bed-hold policy and written notification of transfer at the time of transfer. A third resident had diagnoses including DM, a chronic ulcer of the left foot, major depressive disorder, PVD, heart failure, absence of the right leg below the knee, fracture of the left femur, sepsis, and COPD. The resident’s MDS documented intact cognition, substantial to maximal assistance needs for some ADLs, pain affecting sleep and daily activities, and an unstageable pressure ulcer. The resident had an unplanned short-term hospital discharge and later returned to the facility. Staff and administrative interviews showed confusion about who was responsible for completing the bed-hold process, and the facility lacked a policy regarding written notification upon transfers.
Failure to Complete Significant Change MDS After Hospice Discontinuation
Penalty
Summary
The facility failed to identify a significant change in Resident 54's condition and did not complete a comprehensive Significant Change MDS when hospice services were discontinued. Resident 54's record documented multiple diagnoses, including major depressive disorder, COPD, age-related cognitive decline, HTN, lack of coordination, muscle weakness, CHF, PVD, and schizophrenia. The Quarterly and Annual MDS records showed changes in hospice status over time, and the most recent MDS documented that the resident received hospice services, had a BIMS score of 99 indicating severely impaired cognition, and was dependent on staff for all ADLs. Resident 54's CAA documented that cognition would be addressed in the care plan, with staff monitoring for acute mental status changes and communicating using short, simple sentences. The care plan later documented that hospice services were discontinued and palliative care began, with interventions focused on managing symptoms such as air hunger, pain, agitation, restlessness, constipation, and other discomfort. However, the clinical record lacked evidence that the facility completed a Significant Change MDS to address the discontinuance of hospice services. During interview, the Administrative Nurse stated she was unaware that a Significant Change MDS needed to be completed when a resident went off hospice or onto palliative care.
Failure to Follow Ordered Daily Weights and Fluid Restriction
Penalty
Summary
The facility failed to consistently follow a physician’s order for daily weight monitoring for a resident with fluid overload and failed to ensure the resident’s ordered fluid restriction was monitored. The resident had diagnoses including fluid overload, edema, renal insufficiency, heart failure, hypertension, diabetes mellitus, venous insufficiency, and an acquired absence of the left leg below the knee. The resident’s MDS documented intact cognition with a BIMS score of 15, and the care assessment and care plan identified the need for staff assistance with ADLs, daily weights, intake and output monitoring, and notification of the physician for weight gain over three pounds in one day or five pounds in a week. The physician’s orders included daily weights, a 1500 ml fluid restriction, and specific fluid allowances for meals and medication passes. However, the EMR weights and vitals record showed weights were obtained only on Monday, Wednesday, and Friday, with no documented weights for Tuesday, Thursday, Saturday, or Sunday. The TAR documented a nursing signature for fluid restriction, but the EMR lacked documentation of meals consumed daily. During observation, the resident was found lying in bed asleep or with eyes shut on multiple occasions. Staff interviews showed the process for weights depended on nursing giving CNA staff a list of residents to weigh, with the aides obtaining the weights and returning the list to the nurse. A nurse stated staff would give the resident fluids requested and educate the resident on the daily limit, while an administrative nurse stated nursing was to ensure weights were obtained and that the resident was not compliant with the fluid restriction. The facility’s fluid restriction and weight monitoring policies stated fluid restrictions were to be followed according to physician orders and that residents’ weights were to be maintained within acceptable parameters unless the clinical condition or resident preferences indicated otherwise.
Failure to Monitor Mattress Settings and Provide Wheelchair Cushion
Penalty
Summary
The facility failed to monitor the low-air-loss mattress for R54 and failed to provide a pressure-reducing device for R16's wheelchair. R54 had multiple diagnoses including COPD, CHF, PVD, schizophrenia, cognitive decline, muscle weakness, lack of coordination, and hypertension. Her MDS documented severely impaired cognition, dependence on staff for all ADLs, and risk for pressure injury, with a pressure-reducing cushion in her chair and a pressure-reducing mattress on her bed. Her care plan and physician order required staff to check the low-air-loss mattress and pump function every shift and verify the correct settings based on weight, and her weight was documented as 128.6 pounds while the mattress was set at 240 pounds. Observation and staff interviews showed the mattress monitoring was not consistent with the documented order. R54 was observed lying in bed on multiple days, and staff stated that all staff checked low-air-loss mattresses and that nurses documented the mattress was set correctly. The administrative nurse stated there was a quality team that checked mattresses every day and that the machines were set by weight. However, the record showed the mattress setting did not match R54's documented weight, and the required monitoring was not demonstrated in the findings. R16 had diagnoses including dementia, muscle weakness, contracture of the right hand, hemiparesis/hemiplegia, and CVA. His MDS documented moderately impaired cognition, limited ROM on one side, substantial to maximum assistance with several ADLs, and risk for pressure-related injuries, with pressure-reducing devices placed on his bed and in his wheelchair. Despite this, R16's wheelchair was observed next to his bed and later used for propulsion without a cushion in place, and no wheelchair cushion was noted in his room. Staff stated that direct care staff and nurses were responsible for ensuring the cushion was in the wheelchair when it was on the care plan, and the administrative nurse stated she expected pressure-reducing devices to be in place for residents at risk of skin breakdown.
Failure to Apply Ordered Right-Hand Splint
Penalty
Summary
The facility failed to ensure a resident received services and treatment for a right-hand contracture to prevent an avoidable reduction in ROM. The resident’s EMR documented dementia, muscle weakness, contracture of the right hand, hemiparesis/hemiplegia, and a CVA. The annual and quarterly MDS assessments documented moderately impaired cognition, limited ROM in the upper and lower extremities on one side of the body, substantial to maximum assistance with multiple ADLs, and risk for pressure-related injuries. The care plan directed that the resident wear a hand brace during the morning and have it removed at bedtime as tolerated, and the physician order required the right-hand splint to be applied in the morning and removed at bedtime every day. During observation, the resident propelled his wheelchair to the dining room without a cushion in the wheelchair, with his right hand tightly closed and without the right-hand splint in place. The resident’s right foot was also observed sliding along the floor under the wheelchair as he propelled himself with his left hand. Staff interviews indicated direct care staff could place a brace or hand splint, but the nurse was responsible for ensuring the splint or brace was on the resident and for signing that it had been applied as ordered. The facility’s restorative nursing policy stated residents identified through assessment would receive restorative services, including splint or brace assistance.
Failure to Complete Monthly Pharmacist Review and Track Ordered Labs
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist’s monthly drug regimen review was completed and addressed by the physician within 30 days for two residents, and failed to ensure the pharmacist identified and reported missing physician-ordered laboratory tests. For one resident, the record showed diagnoses including major depressive disorder, anxiety, epilepsy, CHF, and dementia, with a BIMS score of 7 indicating severely impaired cognition. The resident’s care plan directed nursing staff to obtain ordered lab work and noted that the physician and CP would review medications monthly. Physician orders included CBC, CMP, vitamin levels, valproic acid, and Keppra monitoring at specified intervals, but the monthly medication reviews from September 2024 through August 2025 did not document irregularities related to missing lab tests, and some monthly reviews were not present in the EMR until they were later provided and dated as reviewed by the physician on 09/16/25. For that resident, the EMR lacked evidence of several ordered lab results, including CBC and CMP results from May 2025 and August 2025, Keppra and valproic acid levels from April 2025 and July 2025, and yearly lab work results. The resident was observed in the common area on 09/15/25 with an oxygen tank attached to the back of the wheelchair. A nurse stated she did not work with the pharmacy MMRs and that administrative nurses handled them, while an administrative nurse stated she expected the CP to identify and report irregularities monthly and said the resident’s lab tests should have been discontinued when hospice services began in February 2025. For the second resident, the EMR documented diagnoses including anxiety, paranoid schizophrenia, schizophrenia, and major depressive disorder, with a BIMS score of 15 indicating intact cognition. The resident’s care plan stated nursing staff would obtain ordered laboratory tests and that medications would be reviewed monthly by the physician and pharmacist. Physician orders included yearly vitamin and thyroid labs and quarterly CBC, CMP, and Haldol level testing, but the monthly medication reviews from September 2024 through August 2025 lacked documentation or recommendations regarding missing ordered labs. The EMR lacked evidence of several ordered results, including yearly vitamin B12, T4, TSH, and vitamin D labs, Haldol levels, and CBC/CMP testing, and staff again stated that administrative nurses handled the MMRs and that the medical records staff would ensure physician review and enter orders into the EMR.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll-Based Journal (PBJ) as required. CMS PBJ reports for FY 2024 Q4 and FY 2025 Q1, Q2, and Q3 showed excessively low weekend staffing, even though a review of the facility’s weekend and licensed nurse hours found appropriate weekend and licensed nurse coverage. During an interview on 09/16/25, Administrative Staff A stated she was responsible for PBJ submissions, used software to verify hours before submission, and had made changes related to removing ancillary staff from the total hours, while also stating that the weekend staffing patterns for licensed nurses remained the same. The facility’s PBJ policy, dated 02/25/25, required timely electronic submission to CMS of complete and accurate direct care staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to CMS specifications.
CNA Engages in Abusive Behavior Towards Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident, identified as R1, remained free from staff-to-resident abuse. On the specified date, two CNAs, M and N, were preparing R1 for a shower. During this process, R1, who has severe cognitive impairment and is dependent on staff for transfers, began yelling and swatting at CNA M. In response, CNA M swatted back at R1 and placed her hand over R1's mouth, instructing her to hush. This interaction was witnessed by CNA N, who reported feeling uncomfortable with CNA M's behavior towards R1. R1's medical records indicate a history of hemiplegia, cognitive communication deficits, and generalized anxiety disorder, which contribute to her severe cognitive impairment. The care plan for R1 directed staff to approach her in a gentle and unhurried manner, allowing her to make decisions about her care and providing clear explanations of care activities. Despite these directives, CNA M's actions during the incident were contrary to the care plan, as she engaged in behavior that was abusive and not in line with the facility's policies. The facility's investigation substantiated the abuse, with witness statements from CNA N and Administrative Nurse E supporting the claims against CNA M. Administrative Nurse E's assessment of R1 after the incident revealed that R1 gestured to indicate that her mouth had been covered, corroborating the reports of abuse. The facility's failure to prevent this incident resulted in impaired psychosocial well-being for R1 and placed her at risk for continued abuse.
Removal Plan
- The facility suspended CNA M immediately.
- Administrative Nurse E assessed R1 with no injuries found.
- The facility notified R1's representative, R1's provider, and law enforcement.
- The facility obtained witness statements.
- The facility conducted abuse, neglect, and exploitation training.
- The facility interviewed residents with high BIMS regarding abuse.
- Social Services followed up with R1.
- The facility updated R1's care plan.
- The facility terminated CNA M.
Failure to Immediately Report Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure immediate reporting of staff-to-resident abuse involving a resident with severe cognitive impairment and physical disabilities. The resident, who had a history of hemiplegia, hemiparesis, and cognitive deficits following a cerebrovascular accident, was dependent on staff for transfers and required assistance with activities of daily living. On the day of the incident, the resident was being assisted by two CNAs for a shower when the resident began yelling and swatting at one of the CNAs. In response, the CNA swatted back, taunted the resident, and placed a hand over the resident's mouth to quiet her. The incident was witnessed by another CNA, who felt uncomfortable with the situation and later reported it. However, the report was not made immediately; the witnessing CNA took a break before notifying the administrative nurse about the abuse. The facility's policy required that any allegations of abuse be reported to the administrator immediately, or within two hours if the incident involved abuse or resulted in serious bodily harm. The delay in reporting the incident was a violation of this policy. The facility's investigation confirmed the abusive behavior by the CNA, who was subsequently terminated. The failure to report the abuse immediately placed the resident at risk for further harm. The facility's policy on abuse, neglect, and exploitation was not adhered to, as the staff did not report the incident in a timely manner, which is a critical component of ensuring resident safety and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gardner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Evergreen Community Of Johnson County | 6.2 mi | ★★★★★ | 2 | 0 |
| The Healthcare Resort Of Olathe | 6.5 mi | ★★★★★ | 0 | 0 |
| Hoeger House | 6.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Olathe | 6.8 mi | ★★★★★ | 10 | 0 |
| Azria Health Olathe | 7.5 mi | ★★★★★ | 28 | 1 |
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