Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Healthcare during CMS and state inspections, most recent first.
The facility failed to develop and implement comprehensive care plans for several residents, leading to falls and injuries. A resident's care plan interventions were not followed, resulting in multiple falls, while another resident's care plan lacked dementia care goals. Additionally, staff did not adhere to care plans, causing injuries during transfers. The facility's policies on care planning were not effectively executed, contributing to these deficiencies.
The facility failed to update comprehensive care plans for several residents, including not revising plans after resolving infections, not incorporating new fall prevention measures, and not updating psychiatric and wandering interventions. These deficiencies highlight a lack of timely and individualized care planning.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. From early October, multiple units experienced staffing shortages, with CNAs and licensed nurses falling below required levels. Residents reported long wait times for assistance, and some had to resort to self-care due to the lack of staff response. Interviews with staff confirmed the challenges of managing care with insufficient personnel.
A facility failed to maintain a medication error rate below 5%, resulting in a 38.24% error rate. Errors included improper intravenous administration due to malfunctioning equipment and delayed medication administration for two residents. An LPN cited understaffing as a reason for delays and administered medications in applesauce without an order.
The facility failed to label and store medications properly, with several medication carts containing drugs without open or expiration dates. Additionally, an LPN left a medication cart unattended and unlocked, contrary to facility policy. These deficiencies were observed across multiple units, highlighting lapses in adherence to professional standards.
The facility failed to maintain cleanliness in food service areas, including the main kitchen and resident unit kitchenettes, with observations of debris on appliances and soiled refrigerators. Staff interviews revealed lapses in cleaning protocols and communication issues regarding maintenance needs.
The facility failed to follow proper infection control practices, particularly in the use of PPE on COVID-19 precaution units. Staff were observed improperly wearing and disposing of PPE, and there was a lack of adherence to CDC guidelines. PPE carts were not consistently available, and doors to rooms with droplet precautions were left open.
The facility failed to notify resident representatives and physicians of significant changes in residents' conditions, including falls and new medication orders. One resident's provider was informed a day after a fall with a fracture, another resident's representative was not notified of a fall and hospital transfer, and a third resident's representative was not informed of new Haldol orders.
A resident with Lewy Body Dementia was improperly restrained with a seat belt and alarms, which they could not remove independently, leading to distress and agitation. The facility failed to document interventions, adhere to restraint policies, and obtain informed consent. Staff were unaware of the restraint's adverse effects and did not consistently release the seat belt as ordered.
The facility failed to provide meaningful activities for two residents with cognitive impairments, as evidenced by minimal participation in activities over several months. Despite the facility's policy to adapt activities for residents with various abilities, there were no special accommodations for residents with sensory impairments, leading to a deficiency in meeting their needs.
A resident with a history of stroke, diabetes, and heart failure developed pressure ulcers that were not properly assessed or documented by the facility. The care plan lacked specific objectives and timeframes, and physician-ordered treatments were not consistently administered. Observations and interviews highlighted inconsistencies in wound care management and communication, leading to inadequate care for the resident's pressure ulcers.
Two residents in an LTC facility did not receive appropriate respiratory care. One resident lacked a physician's order for continuous oxygen therapy, despite severe respiratory conditions. Another resident received oxygen from unlicensed personnel, with CNAs setting flow rates and applying nasal cannulas, contrary to facility policy. The DON acknowledged these oversights.
A resident with end-stage renal disease did not receive proper documentation of dialysis care, as the facility failed to maintain records of pre and post-dialysis assessments. Despite the facility's policy requiring such documentation, the resident's dialysis communication book lacked vital signs and access site evaluations for multiple dates. Staff interviews confirmed the absence of documentation in the electronic medical record.
The facility failed to renew its narcotics license, leading to unauthorized destruction of controlled substances. The Director of Nursing missed the renewal process while working from home due to COVID, resulting in the facility operating without a license. The New York State Department of Health Bureau of Narcotics Enforcement issued deficiencies for these regulatory failures.
Deficiencies in Care Plan Implementation and Adherence
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive person-centered care plans with measurable objectives and timeframes for five residents. Specifically, Resident #76's care plan interventions were not implemented following recommendations from the interdisciplinary team to reduce falls and injuries, resulting in subsequent falls. Resident #104's care plan lacked interventions and goals for dementia care, despite the resident's history of dementia, depression, and frequent falls. Additionally, Resident #119, who had fallen multiple times, did not have a care plan developed for falls. The report also highlights incidents where staff did not adhere to existing care plans, leading to resident injuries. For instance, a Certified Nurse Aide transferred Resident #139 alone, contrary to the care plan that required two staff members for transfers, resulting in a skin tear. Similarly, Resident #177 fell when staff did not follow the care plan for transfers. These incidents indicate a failure in implementing and adhering to care plans, contributing to resident harm. The facility's policies on Activities of Daily Living Assistance and Care Planning were not effectively followed, as evidenced by the lack of documented care plans in the Point Click Care system for some residents. Interviews with facility staff, including the Director of Nursing and Assistant Director of Nursing, revealed that updates to care plans were supposed to be triggered by daily reports and overseen by the interdisciplinary team, but this process was not adequately executed, leading to the deficiencies noted in the survey.
Deficiencies in Comprehensive Care Plan Updates
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in response to changing needs and interventions for several residents. For one resident, the care plan for a Clostridium difficile infection was not updated after the infection had resolved, indicating a lack of timely updates to reflect the resident's current health status. Another resident's care plan for falls was not revised to include new interventions after multiple falls, despite recommendations from physical therapy for corrective measures. Additionally, the care plan for behaviors did not include necessary psychiatric consultations or ongoing psychiatric services, and the care plan for altercations was not updated after changes in visiting restrictions for the resident's spouse. The facility also failed to update the care plan for wandering/elopement for a resident after the removal of a wander guard, which was a critical intervention for ensuring the resident's safety. Observations and interviews revealed that the resident continued to exhibit wandering behaviors, yet the care plan did not reflect the removal of the wander guard or any new interventions to address the resident's current needs. This oversight highlights a significant gap in the facility's care planning process, as staff assumed increased monitoring without documented interventions. Another resident's care plan for mood was not revised to include psychiatric consultations or ongoing psychiatric services, despite the resident being on multiple psychotropic medications for behaviors with psychiatric symptoms of dementia. The facility's social services department did not schedule or complete a psychiatric consult, and the care plan lacked interventions for managing the resident's behaviors. This deficiency in care planning indicates a failure to provide comprehensive and individualized care for residents with complex behavioral and psychiatric needs.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, compromising their safety and well-being. From October 5 to October 20, 2024, the facility did not meet the minimum staffing levels of Certified Nurse Aides (CNAs) on multiple shifts across various units. The staffing policy required specific numbers of CNAs and licensed nurses per shift, but these levels were not consistently maintained, as evidenced by staff assignment sheets and resident census data. The facility's staffing policy was based on a Case Mix Index of 1.3, but actual staffing fell short of these requirements. Residents and their family members reported significant delays in receiving care due to inadequate staffing. Several residents expressed concerns about long wait times for assistance, particularly during early morning and late-night hours. One resident mentioned waiting over an hour for help, while another reported having to change their own clothes and bedding after soiling themselves because no staff responded to the call bell. Family members also noted the need to assist residents themselves due to the lack of available staff. Interviews with staff confirmed the challenges posed by insufficient staffing. A Registered Nurse mentioned that staffing was more manageable with four nurses compared to two, highlighting the strain on resources. The facility's failure to maintain adequate staffing levels led to residents experiencing delays in care, with some residents resorting to self-care or relying on family members for assistance. This deficiency was observed across multiple units and shifts, indicating a systemic issue with staffing at the facility.
High Medication Error Rate Due to Administration Delays and Protocol Deviations
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 38.24% during a recertification survey. This deficiency was observed in the administration of medications to three residents. The facility's policy required medications to be administered within one hour of the prescribed time, adhering to the Five Rights of medication administration. However, deviations from these protocols were noted during the survey. One resident, admitted with bacterial infection, limited mobility, and depression, was prescribed intravenous Piperacillin Sod Tazobactam Solution to be administered every six hours. During an observation, it was found that the infusion was being administered by gravity due to malfunctioning infusion pumps, with air bubbles present in the tubing. The registered nurse was unable to provide the correct infusion rate, which contradicted the manufacturer's recommendation for administration over 30 minutes. Another resident with Parkinson's disease, hypertension, and depression, and a third resident with diabetes, hypertension, and severe cognitive impairment, both experienced delays in medication administration. Medications scheduled for 8:00 AM were administered over an hour late. The LPN responsible for these residents cited being the only nurse for 41 residents as the reason for the delay and did not notify anyone about the late administration. Additionally, the LPN administered medications in applesauce without a physician's order, further contributing to the medication errors.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. Specifically, medications on the Aspen, Subacute, and Orchard Units' medication carts were found without open and/or expiration dates. For instance, the Subacute Unit's medication cart contained Lumigan and Dorzolamide eye drops with open dates but no expiration dates. Similarly, the Orchard Unit's cart had insulin pens and eye drops without proper labeling of open and expiration dates. Additionally, the Pine Ridge Unit's cart had insulin pens and an inhaler without open and expiration dates, and the LPN incorrectly assumed the expiration date based on the box rather than the facility's pharmacy grid. Furthermore, the facility did not maintain secure storage of medications as required. During an observation, the Aspen Unit's medication cart was left unattended and unlocked, with a laptop screen displaying a Resident Medication Administration Record. The LPN responsible for the cart admitted to being behind schedule and overwhelmed, as they were the only nurse administering medications to 41 residents. The facility's policy mandates that medication carts be locked and attended at all times to prevent unauthorized access, which was not adhered to in this instance.
Food Service Safety Deficiency
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety across all observed areas, including the main kitchen and six resident unit kitchenettes. Observations revealed significant cleanliness issues, such as a rolling toaster in the main kitchen with a large buildup of debris, and microwaves in multiple resident kitchenettes with food particles along the doors and interiors. Additionally, refrigerators in these areas were found with cracked seals and were soiled with food and liquid particles. Interviews with staff highlighted a lack of adherence to cleaning protocols. The Director of Food Services indicated that kitchenettes should be cleaned daily by staff, but this was not being done. The Director of Housekeeping stated that their staff was responsible for overall cleaning but not inside the refrigerators, and they had not received any work orders for maintenance issues. The Dietary Aide admitted to not performing cleaning duties as required due to time constraints. The Director of Maintenance, new to the position, was unaware of any issues as no work orders had been submitted.
Inadequate Infection Control Practices in COVID-19 Precaution Units
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, particularly in the use of personal protective equipment (PPE) on units with COVID-19 precautions. Observations revealed that a nurse exited a resident's room wearing a cloth gown and removed it in the hallway, contrary to the facility's policy that required PPE to be removed inside the room. Additionally, PPE carts were not consistently available on all units, and doors to rooms with special droplet precaution signs were left open, which was against the protocol for rooms on COVID precautions. Interviews with staff, including the Director of Nursing and various nurses, highlighted a lack of adherence to proper PPE protocols. Staff were observed improperly wearing N-95 masks, and there was a misunderstanding about the CDC guidance regarding the disposal of N-95 masks after caring for residents on isolation for respiratory illnesses. The Director of Nursing was unaware of the current CDC guidance, which contributed to the improper practices observed during the survey.
Failure to Notify Resident Representatives and Physicians
Penalty
Summary
The facility failed to ensure timely notification of resident representatives and physicians regarding changes in residents' conditions, which led to deficiencies in care. For one resident, the facility did not notify the provider until the day after the resident experienced a fall resulting in a fracture and subsequent hospital admission. This delay in communication was contrary to the facility's policy, which mandates immediate notification of significant incidents. Another resident experienced a fall and required x-rays, but the resident's representative was not informed until much later, after the resident had been sent to the hospital. The facility's documentation showed that attempts were made to contact the representative, but these were unsuccessful, resulting in the representative being unaware of the resident's condition and hospital stay. A third resident received multiple doses of Haldol Lactate Solution for behavioral issues without the resident's representative being notified of the new medication orders. The facility's records lacked documentation of any notification to the representative, which was acknowledged as an oversight by the nursing staff. This failure to communicate significant medication changes was inconsistent with the facility's policy and regulatory requirements.
Failure to Ensure Resident's Right to be Free from Unnecessary Restraints
Penalty
Summary
The facility failed to ensure that Resident #198 was free from physical restraints that were not required to treat medical symptoms. The resident, who was admitted with diagnoses including Lewy Body Dementia and a history of falls, was observed with a chair alarm and a seat belt that they could not remove independently. The facility's policy on restraints indicated that physical restraints should only be considered after all other interventions were exhausted, and the restraint should be documented each time it was applied or removed. However, there was no evidence of documented interventions or consistent adherence to the policy. Observations during the survey revealed that Resident #198 was often restrained with a seat belt and alarms, which were not consistently released as per the physician's order. The resident was observed in distress, unable to release the seat belt, and was not provided with adequate activities to engage in, leading to agitation. Interviews with staff indicated a lack of awareness and documentation regarding the restraint's adverse effects and the required release schedule. The facility's care plan and progress notes did not adequately address the resident's needs or document informed consent for the use of restraints and alarms. The facility's failure to properly assess and document the use of restraints, as well as the lack of informed consent and monitoring for adverse effects, contributed to the deficiency. The resident's care plan included various alarms and a seat belt as safety interventions, but these were not effectively managed or evaluated. The Director of Nursing acknowledged that the seat belt did not have a separate assessment and was considered a safety intervention without requiring a physician's order, highlighting a gap in the facility's compliance with regulations regarding restraint use.
Deficiency in Providing Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide ongoing programs to support the interests and well-being of residents, specifically for two residents with cognitive impairments. Resident #104, diagnosed with dementia, polymyalgia rheumatica, and other conditions, was observed to be confused and restless in the common area without engaging in meaningful activities. Despite the facility's policy to adapt activities for residents with various abilities, Resident #104's activity log showed minimal participation in activities over several months, indicating a lack of consistent engagement in programs designed to enhance their quality of life. Similarly, Resident #119, who has visual impairment, chronic obstructive pulmonary disease, and dementia, also experienced inadequate activity engagement. The activity log for Resident #119 showed participation in activities on only a few occasions over several months. Interviews with facility staff revealed that there were no special accommodations for residents with sensory impairments, and all residents attended the same activities. This lack of individualized programming and accommodation contributed to the deficiency in meeting the residents' needs for meaningful activities.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had a history of cerebral infarction, diabetes, and congestive heart failure, was admitted with no documented wounds. However, an unstageable pressure ulcer on the right great toe was identified later, and the facility did not complete accurate assessments or documentation for this wound and another on the second toe of the left foot. The care plan lacked measurable objectives and timeframes to promote healing, and physician-ordered treatments were not administered as ordered. The facility's policy on pressure ulcer prevention and management was not followed, as evidenced by the lack of thorough skin assessments and documentation. The treatment orders for the resident's wounds were inconsistently documented and not properly executed. For instance, a treatment order for skin prep was not recorded on the Treatment Administration Record, and there was no evidence that the treatment was administered. Additionally, the care plan did not specify the location of the wounds or document the necessary interventions. Observations and interviews revealed further inconsistencies in wound care management. The resident's wounds were not consistently assessed or documented, and there was a lack of communication between nursing staff and physicians regarding the resident's condition. The resident's family expressed concerns about the care provided, and there was no documentation of follow-up actions requested by the family. The facility's failure to adhere to professional standards of practice resulted in inadequate care for the resident's pressure ulcers.
Deficiencies in Oxygen Administration and Documentation
Penalty
Summary
The facility failed to ensure that each resident received necessary respiratory care in accordance with professional standards of practice. Specifically, for Resident #9, there was no physician's order for the oxygen therapy that the resident was receiving. Despite being on continuous oxygen therapy due to severe respiratory conditions, including asthma, chronic obstructive pulmonary disease, and respiratory failure, the facility's records, including the Treatment Administration Record and Medication Administration Record, did not document an order for oxygen. Observations confirmed that Resident #9 was on oxygen at 2 liters per minute, yet the Director of Nursing acknowledged that an order should have been in place but was missed. For Resident #122, the deficiency involved the administration of oxygen by unlicensed personnel. The resident, who had chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, was observed receiving oxygen from a Certified Nurse Aide who set the flow rate and applied the nasal cannula. Interviews with staff revealed that Certified Nurse Aides were performing tasks such as setting oxygen flow rates and changing oxygen tubing, which should have been the responsibility of licensed nursing staff. The Director of Nursing confirmed that while Certified Nurse Aides could place nasal cannulas, they were not permitted to set the flow rate or turn on the oxygen. These deficiencies highlight a lack of adherence to the facility's policy requiring a physician's order for oxygen use and the proper delegation of tasks related to oxygen administration. The facility's failure to ensure proper documentation and adherence to professional standards of practice for oxygen administration resulted in these deficiencies being identified during the survey.
Inadequate Dialysis Care Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as evidenced by the lack of ongoing assessments and oversight before and after dialysis treatments. The facility's policy required that a Dialysis Communication Book be maintained for each resident receiving hemodialysis, with pre and post-dialysis assessments documented in the electronic medical record. However, for the resident in question, there was no documentation of post-dialysis vital signs, weights, or evaluation of the dialysis access site for multiple dates, and no forms were available to document dialysis evaluations for several other dates. The resident, who was admitted with end-stage renal disease, sepsis, and depression, was noted to be cognitively intact and able to communicate effectively. Despite the facility's care plan interventions, which included monitoring vital signs and the dialysis access site, the resident's dialysis communication book lacked necessary documentation. Interviews with facility staff revealed that while assessments were reportedly conducted, the missing data in the communication book could not be accounted for, and there was no documentation in the electronic medical record.
Failure to Renew Narcotics License and Unauthorized Destruction of Controlled Substances
Penalty
Summary
The facility failed to ensure proper procedures for the handling of narcotic medications, specifically in the destruction of controlled substances. During a recertification and abbreviated survey, it was found that the facility did not have a valid narcotics license at the time of the destruction of controlled substances. This was due to the failure to renew the narcotics license, which was a requirement for the destruction process. The Director of Nursing, who was responsible for the renewal, missed the renewal process while working from home due to contracting COVID, resulting in the facility operating without a license. The New York State Department of Health Bureau of Narcotics Enforcement issued statements of deficiencies to the facility for operating without a license and for the unauthorized destruction of controlled substances. The Director of Nursing acknowledged the lapse in following the established procedure for license renewal, which led to the oversight. This incident highlighted the facility's failure to comply with the necessary regulatory requirements for handling controlled substances, as they did not have the required approval from the Department for the destruction of narcotics.
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Illustrative
What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Plattsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Champlain Valley Physicians Hosp Med Ctr S N F | 0.4 mi | ★★★★★ | 0 | 0 |
| Plattsburgh Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Clinton County Nursing Home | 1.8 mi | ★★★★★ | 0 | 0 |
| Elderwood At Burlington | 16.6 mi | ★★★★★ | 15 | 0 |
| Birchwood Terrace Rehab & Healthcare | 16.7 mi | ★★★★★ | 2 | 0 |
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