Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook Care Center during CMS and state inspections, most recent first.
An LPN administered morning meds to multiple residents well outside the ordered time window, with several 8:30 AM meds documented around 11:37 AM to 11:55 AM. The DON, physician, and medical director stated meds should generally be given within one hour before or after the ordered time, while the LPN said they were unfamiliar with the unit and the unit manager said they were occupied with treatments and did not realize 12 residents still needed morning meds.
An infection control deficiency involved three residents. An LPN wore the same gloves after handling a bathroom sink and then prepared to flush a gastrostomy tube, another LPN handled a potassium chloride tablet with bare hands before breaking it in half, and a CNA entered a resident’s contact-precaution room without PPE before later donning gown and gloves. The residents involved included one with a feeding tube and severe cognitive impairment, one cognitively intact resident receiving oral meds, and one on contact precautions for MDR organisms in urine and wounds.
A resident with cancer, hip fracture, and anxiety disorder developed fever, shivering, and low O2 sat, and the MD ordered labs plus a chest x-ray. Nursing documented the order was sent to the x-ray vendor, but the record showed no evidence the x-ray was completed, and there was no documented follow-up when it was missed. The resident later became confused and uncontrollably shaky, was transferred to the hospital, and was admitted with pneumonia.
Medications were found left on two residents’ overbed tables instead of being secured in the med cart. One resident had an unlabeled bottle of Tums with no MD order or self-administration assessment, and another resident had Lotrimin cream left in the room despite no self-administration assessment or order. Both residents had BIMS scores of 12, indicating moderate cognitive impairment, and no nursing staff were nearby when the medications were observed.
A survey revealed a discrepancy in the controlled drug count on Unit 1B, where an LPN failed to document the administration of an Oxycodone tablet for a resident, resulting in a mismatch between the controlled substance record and the blister pack. The facility's policy mandates immediate documentation to ensure accountability and security.
The facility's assessment inaccurately documented the need for 57 CNAs during the day shift, which was identified as a typographical error. The Administrator acknowledged the discrepancy, stating the number did not reflect the actual staffing needs based on residents' acuity levels. A revised assessment later indicated that 39 CNAs were required.
A resident with Chronic Obstructive Pulmonary Disease and other conditions was observed receiving oxygen therapy without a physician's order, contrary to facility policy. Staff interviews revealed a lack of awareness regarding the absence of the necessary order, highlighting a failure to maintain medical records in accordance with professional standards.
The facility failed to transmit MDS assessments to CMS within the required 14-day period for three residents. One resident's discharge assessment was 132 days late, another's quarterly assessment was 16 days late after an initial rejection, and a third's discharge assessment was 90 days late. The facility's policy lacked a specified timeframe for transmission, and the DON was unaware of the process, which was the responsibility of the MDS Coordinators.
Late Medication Administration on Unit 3A
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when 12 residents on Unit 3A did not receive morning medications within the facility’s required two-hour administration window. The facility’s policy stated medications are to be administered within one hour before or after the ordered time, and the unit’s medication schedule listed 8:30 AM as the standard time for once-daily, twice-daily, three-times-daily, and four-times-daily medications unless otherwise ordered by the physician. During the medication storage observation, an LPN was still administering morning medications in the dining room at 11:01 AM and stated that several residents still had morning medications remaining to be given. Record review showed that Resident #175, who had hypertension, cerebral infarction, and gastrostomy status, had 8:30 AM orders for amlodipine, metoprolol tartrate, and clopidogrel, but the Medication Administration Audit Report documented those medications were given at 11:55 AM. Resident #31, who had hypertension, peripheral vascular disease, and myocardial infarction, had 8:30 AM orders for metoprolol tartrate and clopidogrel, but the audit report documented administration at 11:47 AM. Resident #271, who had diabetes mellitus with hypoglycemia, hypertension, and polyneuropathy, had 8:30 AM orders for Janumet and Jardiance, but the audit report documented administration at 11:37 AM. The DON stated that medications should be administered within a two-hour timeframe and that 8:30 AM medications should be given between 7:30 AM and 9:30 AM. The DON also stated that the medication nurse should notify the unit manager if help is needed and that residents should not receive medications late. The LPN stated they were not regularly assigned to Unit 3A, were late because they were unfamiliar with the residents and adjusting to the workload, and had asked the unit manager for help. The unit manager stated the request for assistance came shortly before 11:00 AM and that they did not realize 12 residents still needed morning medications because they were occupied with scheduled treatments. The physician and medical director both stated medications should generally be administered within one hour before or after the ordered time.
Infection Control Breaches During Medication Administration and Contact Precautions
Penalty
Summary
The facility failed to provide an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for three residents. During medication administration observation, an LPN wore gloves while filling an irrigation bottle with tap water from a bathroom sink for a resident with a gastrostomy tube, then went to the bedside and prepared to flush the tube without changing gloves or sanitizing hands. The resident had diagnoses including cerebrovascular accident, respiratory failure, and a feeding tube, and had severe cognitive impairment on the most recent MDS assessment. For another resident, an LPN handled a potassium chloride tablet with bare hands after the resident said the tablet was too large to swallow and requested it be cut in half. The nurse discarded that tablet, sanitized hands, then popped another tablet from the blister pack using bare hands and broke it in half for administration. The resident was cognitively intact and had physician orders for regular food consistency and thin liquids. A third resident had physician-ordered contact precautions for colonization of carbapenem resistant Enterobacterales in the urine and methicillin resistant staphylococcus in lower extremity wounds. A CNA entered the resident’s room without the PPE required by the posted contact precaution signage, placed a meal tray on the bedside table, and adjusted items on the table before stepping out, performing hand hygiene, and then putting on a gown and gloves before re-entering. The resident had diagnoses including multidrug-resistant infection, chronic venous ulcers, and urinary incontinence, and the care plan included contact precautions.
Missed Chest X-Ray Order for Febrile Resident
Penalty
Summary
The facility failed to ensure that a chest x-ray ordered for a resident with fever was obtained in a timely manner. The resident had diagnoses including cancer, hip fracture, and anxiety disorder, and the admission MDS documented a BIMS score of 11, indicating moderate cognitive impairment. On 03/09/2026, the resident was observed flushed, shivering, febrile at 101.9 degrees Fahrenheit, with elevated blood pressure and an oxygen saturation of 92% on room air. The physician was notified and ordered blood work, urinalysis, urine culture and sensitivity, and a chest x-ray. A physician order documented a chest x-ray to be obtained that night, and nursing notes later documented that laboratory results were pending, with abnormal urinalysis and blood test results reviewed with the physician. A physician assistant later documented that the resident was awake, alert, and oriented to person and place with periods of forgetfulness, denied respiratory and urinary symptoms, and had stable respiratory status, while noting that chest x-ray and urine culture and sensitivity results would be followed up for further intervention. However, the medical record contained no evidence that the chest x-ray was completed as ordered. The resident later developed shaking uncontrollably and confusion, and the family requested transfer to the hospital, where the resident was admitted with pneumonia. Interviews with nursing leadership and the x-ray vendor indicated the requisition had been sent, but the vendor could not locate it and there was no documentation of follow-up in the medical record regarding the missed x-ray. The Director of Nursing stated the x-ray was not done and that the order should have been completed within 24 hours, but no progress notes documented the communication with the physician or the vendor regarding the missed test.
Medications Left Unsecured and Unlabeled at Residents’ Bedsides
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles. During observations, an unlabeled bottle of Tums was found on a resident’s overbed table, and a labeled tube of clotrimazole cream was also left on another resident’s overbed table. In both instances, there was no nursing staff in the vicinity of the rooms at the time of observation. Resident #5 had diagnoses including atrial fibrillation, GERD, and diabetes mellitus, and the annual MDS documented a BIMS score of 12, indicating moderate cognitive impairment. The resident’s care plan addressed abdominal discomfort and included medications as ordered by the physician, but the electronic record did not show a physician’s order for Tums or a self-administration assessment. During the observation, the unlabeled bottle of Tums was present on the overbed table while the resident was lying in bed. Resident #13 had diagnoses including COPD, diabetes, and rash, and the annual MDS also documented a BIMS score of 12, indicating moderate cognitive impairment. The resident had a physician’s order for Lotrimin 1% cream to be applied to the right posterior upper arm twice daily for 14 days, and the care plan addressed skin integrity and rash. However, the record did not show a self-administration assessment or order to self-administer the medication, and the cream was observed left on the overbed table while the resident was lying in bed.
Controlled Drug Count Discrepancy
Penalty
Summary
During a recertification survey, it was found that the facility failed to accurately maintain an account of controlled drugs on Unit 1B. Specifically, the count of Oxycodone tablets documented in the controlled substance record did not match the actual number of tablets present in the blister pack for a resident. The facility's policy requires that all controlled drugs be subject to special receipt, handling, storage, disposal, and record keeping to ensure accountability and security. However, during an observation, it was noted that the controlled drug record sheet indicated 29 tablets remaining, while the blister pack contained only 28 tablets. The discrepancy was attributed to an oversight by an LPN who administered a 5-milligram Oxycodone tablet to the resident but failed to record the administration on the controlled drug record sheet. The resident's medication administration record was signed, indicating the medication was administered as ordered. Interviews with the Nurse Educator and the Director of Nursing Services confirmed that the procedure requires nurses to document the removal of controlled medication immediately on the controlled drug record sheet to ensure the narcotic count matches.
Inaccurate Facility Assessment of CNA Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately reflected the necessary resources to care for residents competently during day-to-day operations. Specifically, the assessment incorrectly documented the need for 57 Certified Nurse Aides (CNAs) during the day shift, which included 39 facility staff and 18 agency staff. Upon review, the Administrator acknowledged that this number was a typographical error and did not accurately represent the actual number of CNAs required based on the residents' needs and acuity levels. The Administrator admitted that the information should have been accurate and up-to-date when the assessment was reviewed in May 2024. A revised assessment was later provided, indicating that 39 CNAs were required for the day shift.
Resident Received Oxygen Without Physician's Order
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, as evidenced by the case of a resident receiving oxygen therapy without a physician's order. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Acute Kidney Failure, was observed receiving 2 liters of oxygen per minute via a nasal cannula on multiple occasions. Despite the facility's policy requiring a physician's order for oxygen therapy, there was no documented evidence of such an order for this resident. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Unit Manager, revealed that the staff were unaware of the lack of a physician's order for the resident's oxygen therapy. The LPN admitted to not checking the resident's physician's orders and acknowledged that they should have verified the presence of an order before administering treatments. The Director of Nursing Services also confirmed that a physician's order should have been in place for the resident receiving oxygen therapy.
Delayed MDS Assessment Submissions
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day timeframe. This deficiency was identified during a recertification survey for three residents. Specifically, one resident's discharge MDS assessment was submitted 132 days late, another resident's quarterly MDS assessment was submitted 16 days late after an initial rejection, and a third resident's discharge MDS assessment was submitted 90 days late. The facility's policy on MDS assessments, last revised in 2019, did not specify the timeframe for transmitting assessments. Interviews revealed that the Director of Nursing Services was unaware of the MDS transmission process, which was the responsibility of the MDS Coordinators. One of the MDS Coordinators admitted to not ensuring the timely submission of the assessments, leading to the significant delays in transmission.
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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 Freeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Shore Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Mount Sinai South Nassau T C U | 1.9 mi | ★★★★★ | 1 | 0 |
| Oceanside Care Center Inc | 2.6 mi | ★★★★★ | 5 | 0 |
| Rockville Skilled Nursing & Rehabilitation Center, | 3 mi | ★★★★★ | 0 | 0 |
| The Grand Pavilion For Rehab & Nursing At Rockvill | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.