Meadowbrook Health Care Center, a nursing home located in Hemet, California, received 20 citations for health and safety deficiencies in its most recent inspection, on April 20, 2019. According to Centers for Medicare and Medicaid Services records accessed on February 26, 2020, that figure numbers more than the statewide average of 12.8 citations, and more than U.S. average of 8.0. A for-profit corporation owned by Johnre Care Inc., Meadowbrook Health Care Center is a Medicare and Medicaid participant with 64 certified beds and an average of 48.8 residents at the facility per day. The deficiencies described in the April 2019 citations include the following:
- The nursing home did not ensure residents were provided with appropriate treatment. Federal code requires nursing homes to provide residents with “appropriate treatment and care according to orders, resident’s preferences and goals.” An inspection found that Meadowbrook Health Care Center did not provide such in an instance when the facility did not “ensure signs and symptoms of bleeding were monitored” per the plan of care of a resident reviewed for side effects of blood thinner medication. The citation states further that the failure to ensure such “may have contributed” to the resident being sent to the emergency room for rectal bleeding. According to the citation, the resident was receiving an anticoagulant agent to prevent blood clots, and the plan of care stated that they should be monitored for signs and symptoms of excessive anticoagulation. A Licensed Vocational Nurse confirmed to state authorities, however, that “there was no documentation” the resident was being monitored such during the month in question, and “should have been monitored” in the period leading up to the resident being sent to the hospital.
- The nursing home did not ensure the competencies of food and nutrition services staff. Federal code requires nursing homes to ensure that its staff have “appropriate competencies and skills sets to carry out the functions of the food and nutrition service.” An inspection found that Meadowbrook Health Care Center failed to ensure its supervisory staff failed to carry out their key functions in an instance wherein the facility’s Dietary Manager and Registered Dietitian “did not provide management and oversight to ensure food was stored, prepared, and served according to facility and industry standards,” as well as that equipment and other food service items were maintained in good working condition. The citation goes on to state specifically that an inspector found that the facility’s RD did not ensure residents were provided with “a comparable in nutrient content alternate” when they requested one instead of the “main entrée.” The inspector also found that the RD did not “report the poor condition” of certain food service items, and that cutting boards and cooking pans were not maintained in good condition. The citation states that these deficiencies resulted in the potential for the facility’s residents to experience “food borne illness and nutritional related health complications.”