The Meadows Post Acute

Based on interview and record review, the facility failed to follow-up with the Preadmission Screening and Resident Review (PASARR- a mandatory federal program requiring all applicants to Medicaid-certified nursing facilities to be screened for serious mental illness [SMI] or intellectual disability [ID/DD]) recommendation to obtain a PASARR Level II evaluation (an in-depth, mandatory assessment conducted when a Level I screen indicates a potential SMI, ID/DD, or related condition [RC]) for one of one sampled residents (Resident 3). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 5/15/2024 and readmitted Resident 3 on 12/11/2025 with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mental disorder that causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise Resident 10's comprehensive person-centered care plan to include sufficiently specific and individualized interventions addressing supervision, monitoring and access to smoking materials after identifying ongoing non-compliance with smoking safety protocol, for one of one resident reviewed for smoking safety. The care plan failed to address: 1. Process of supervision by the receptionist between 8:00 a.m. and 8:00 p.m.2. Interventions to ensure other residents do not light Resident 10's cigarette.3. Activity staff monitoring while Resident 10 is smoking. 4. Specific measures to prevent burn injury related to lighter use.5. Clear parameters governing Resident 10's access to cigarette lighters. 6. Designated staff roles and responsibilities for monitoring smoking activities. This deficient practice had the potential to result in burn injury to Resident 10 and others and posed a risk to resident safety. Findings: During a review of Resident 10's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice by failing to reconcile and clarify a pending ophthalmology consult order upon hospital readmission for one of one (Resident 11) resident reviewed for vision services. The facility failed to: 1. Ensure a previously ordered ophthalmology consult for cataract evaluation remained active or was clarified with the physician upon the resident's return from a general acute care hospital (GACH). 2. Review and clarify any previously scheduled specialist appointments at the time of readmission to determine whether they should be continued, discontinued, or rescheduled, in accordance with the facility's readmission process. These deficient practices resulted in a delay in ophthalmologic evaluation and cataract treatment for Resident 11. Findings:During a review of Resident 11's Face Sheet, the facesheet indicated the resident was admitted to the facility on [DATE] and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted daily for two of two days on 2/11/2026 and 2/12/2026. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.Findings: During an observation on 2/11/2026 at 12:10 p.m., observed posted in nurse's station 1, framed, the facility document titled, Census and Direct Care Service Per Patient Day (DHPPD- the number of hours worked by nurses or aides in relation to the number of patients within a facility at a given time), dated 2/11/2025. During an interview on 2/11/2026 at 12:12 p.m., with Registered Nurse 5 (RN 5), RN 5 stated that the Director of Staff Development (DSD) is responsible for posting daily nursing postings. During a concurrent observation and interview on 2/12/2026 at 10:37 a.m., observed posted in nurse's station 1, framed, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure buprenorphine (used to treat pain and opioid use disorder [chronic use of opioids that causes clinically significant distress or impairment]) was administered sublingually (method of administering medication by placing it under the tongue to dissolve) as per the physician's order for one of five sampled residents observed during medication administration. This deficient practice had the potential for the medication not to work as intended, which can lead to the return of opioid withdrawal symptoms (physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance) and cravings. Findings: During a review of Resident 92's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/22/2024 and readmitted the resident on 2/6/2026 with diagnoses including muscle weakness and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 92's History and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided with a Magic Cup (a high-calorie, high-protein nutritional supplement designed for individuals needing to gain weight or requiring specialized diets) as ordered by the physician for one of one sampled residents (Resident 93). This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility admitted Resident 93 on 1/20/2026 with diagnoses that included metabolic encephalopathy (underlying systemic conditions or substances that disrupt the brain's chemical balance, leading to brain dysfunction), dysphagia (difficulty swallowing), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]). During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) by failing to provide a clean shower room.This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to negatively impact their quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/10/2024 and readmitted the resident on 2/1/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of left hip and immunodeficiency (a condition where the immune system is weakened, making the body unable to fight off infections and diseases effectively, leading to frequent or severe illnesses from germs that a healthy immune system would normally handle).During a review of Resident 1's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) responsible party (RP) was informed of the Interdisciplinary Team (IDT - a group of professionals from different fields who collaborate to achieve a common goal for the resident) Care Conference on 4/8/2025. This deficient practice violated Resident 1's RP right to participate in decisions regarding Resident 1's care, treatment and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility especially in the fingers, wrists, feet and ankles) and type 2 diabetes mellitus (a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely intervention following notification from an outpatient infusion clinic (a medical facility where residents receive medications and fluids through intravenous [IV - administered into a vein] without being admitted to the hospital) regarding Remicade (with the generic name infliximab, a medication used to treat a range of inflammatory medical conditions including rheumatoid arthritis [RA - a condition causing joint pain and inflammation]) treatment for one of six sampled residents (Resident 1) after Registered Nurse 1 (RN 1) received notification from the outpatient infusion clinic on 5/5/2025 at 12:15 p.m. that the outpatient clinic could not administer the Remicade IV due to Resident 1 being admitted to the facility. This deficient practice resulted in Resident 1 not receiving the Remicade IV treatment resulting in a delay of the treatment and placed Resident 1 at increased risk for joint inflammation, pain and deterioration in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) received two (2) liters (a unit of measurement) of oxygen continuously according to the physician's order. This deficient practice had the potential to result in Resident 1 not receiving sufficient oxygen levels in the body, shortness of breath, difficulty with speaking, confusion, and decreased quality of life. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 4/7/2025 with diagnoses that included cerebral palsy (a group of conditions that affect movement and posture), chronic pulmonary edema (an abnormal buildup of fluid in the lungs), and bronchopneumonia (infection in the upper part of the airway). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility: 1. Failed to administer a physician prescribed medication for itchiness for one of one (Resident 43) resident investigated under pharmacy services. This deficient practice had the potential to cause the resident to have unrelieved itchiness which could result to prolonged itching and scratching possibly leading to skin injury, infection, and scarring. 2. Failed to implement the facility's medication administration policy by failing to obtain a physician's order prior to the administration of the COVID-19 (a mild to severe respiratory illness that is caused by the coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (shots that one take to teach the body's immune system to recognize and defend against harmful germs) for two out of five sampled residents. (Resident 30 and Resident 68) This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects due to not receiving a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) by failing to: 1. Ensure there was documented evidence in the resident's medical record indicating a hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 30) 2. Ensure there is a designated facility staff to coordinate care and services provided by the hospice provider and the facility. These failures that the potential to prevent Resident 30 from receiving well-coordinated and comprehensive hospice services. Findings: 1. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 10/9/2014, with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation on 11/22/2024 at 6:21 p.m., observed laundry staff walking in the hallway transporting a cart of clothes uncovered. During an observation and concurrent interview with Laundry Staff 1 (LS 1) on 11/22/2024 at 6:22 p.m., observed LS 1 transporting a cart of laundry uncovered. LS 1 stated that the cart of clothes are residents' clean clothes from the laundry. LS 1 stated that when transporting clean clothes and linen the clean laundry should be covered so that the clean clothes and linen do not get dirty and contaminated. LVN 1 further stated that the clean laundry cart should have been covered but she forgot to cover the clean laundry cart prior to transport. During an interview with the Infection Preventionist (IP) on 11/24/2024 at 3:58 p.m., the IP stated that clean laundry and linen should always be transported covered to prevent clean laundry and linen from getting dirty, contaminated, and for infection control. During a review of the facility's policy titled Laundry and Bedding,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) was completed timely for one (Resident 63) out of 21 sampled residents. This deficient practice had the potential to negatively affect the provision of necessary care and services for this resident. Findings: During a review of Resident 63's admission Record, the admission Record indicated the facility originally admitted the resident on 5/27/2021 and readmitted the resident on 5/24/2022 with diagnoses including neuropathy (a disease that occurs when nerves are damaged, resulting in pain, numbness, tingling, weakness, or swelling in various parts of the body) and difficulty in walking. During a review of Resident 63's History and Physical (H&P - a formal assessment by a healthcare provider that involves a patient interview, physical exam, and documentation of findings), dated 11/7/2024, the H&P indicated the resident has the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions healthcare treatments that are not primarily based on medication) prior to administering as needed (PRN) opioid pain medication (powerful pain-reducing medications) on multiple dates for two (Residents 7 & 8) out of three sample residents investigated under the care area of pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration. Findings: a. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and a history of falling. During a review of Resident 7's History and Physical (H&P - a comprehensive assessment of a patient that includes taking a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. A bag of wheat bread and English muffin were not labeled with an open date. b. A resident's food from home in the resident's refrigerator had no label and no received date. These deficient practices had the potential to place 83 out of 92 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 11/22/2024 at 07:45 p.m., with Dietary Manager 1 (DM 1) in the facility`s kitchen, observed a bag containing eight (8) slices of wheat bread and a bag containing three English muffins, without an open date label. DM 1 stated when a bag of bread is opened, the bag must be labeled with the open date so the kitchen staff would know when to discard the bread. DM 1 stated that labeling will ensure that food items are still safe for residents to consume. DM 1 stated there is a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their policy on rehabilitation screening as evidenced by the facility failing to conduct a quarterly rehabilitation screen for one of three sampled residents (Resident 68). This deficient practice placed Resident 68 at risk for not maintaining, improving or restoring the resident's functional abilities. Findings: During a review of Resident 68's admission Record, the admission Record indicated the facility originally admitted the resident on 9/6/2022, with diagnoses including vascular dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and cerebral palsy (a group of movement disorders that can cause problems with posture, manner of walking, muscle tone, and coordination). During a review of Resident 68's Minimum Data Set (a resident assessment tool), the MDS dated [DATE], indicated Resident 68's cognition skills required for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review the failed to develop a facility policy and procedure (P&P) specific for a Physician Orders for Life-Sustaining Treatment (POLST- a medical order that outlines a resident's end of-life care preferences, a physician, nurse practitioner (an advanced practice registered nurse and a type of mid-level practitioner), or physician's assistant (a licensed health care professional who works with physicians to provide care) must sign the form, along with the resident; or their legally recognized health care decision maker). This deficient practice had the potential to bring confusion to facility staff or a delay of care in an event a resident becomes unresponsive. Findings: During a review of Resident 101's admission Record, the admission Record indicated the facility originally admitted the resident on 10/19/2024, with diagnoses that included hyponatremia (low sodium levels), lung disease, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain). During a review of Resident 101's History and Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility's Coronavirus Disease (COVID-19- a mild to severe respiratory illness that is caused by coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (prevents infection) policy by failing to ensure residents were screened for eligibility prior to the administration of the vaccine for two of five sampled residents (Resident 30 and Resident 68). This deficient practice had the potential for residents to receive vaccines that he/she is not eligible for or contraindicated, resulting in adverse (an undesirable or harmful effect) events. Findings: a. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 10/9/2014, with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and Parkinson's disease (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility staff (Certified Nurse Assistant 1 [CNA 1]) knocked on a resident's door before entering the resident's room for one of three sampled residents (Resident 3). This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: During a review of Resident 3's admission Record, indicated that the facility originally admitted Resident 3 on 3/26/2024 and readmitted on [DATE], with diagnoses including muscle weakness, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pneumonia (infection that inflames air sacs in one or both lungs). During a review of Resident 3`s History and Physical dated 7/13/2024, indicated Resident 3 does not have the capacity to understand and make decisions. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure one of nine sampled staff (Licensed Vocational Nurse 1 [LVN 1]) wore an isolation gown (protective apparel, used to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) and a face shield (a protective covering for all or part of the face that is commonly made of clear plastic and is worn especially to reduce the spread of transmissible disease) before entering Resident 2's room which was placed on novel respiratory precautions (NRP - precautions should be used for residents known or suspected to be infected with {Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]}). These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID-19. Findings: During a review of Resident 2's admission Record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's call light (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for one of seven sampled residents (Resident 2). On 5/23/2024, observed Resident 2's call light hanging behind Resident 2's headboard frame. Resident 2's call light was out of Resident 2's reach. This deficient practice had the potential to result in a delay with resident care, and residents not receiving assistance with activities of daily living (ADL- fundamental skills required to independently care for oneself, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Findings: A review of Resident 2's admission Record indicated the facility originally admitted the resident on 10/15/2022 and readmitted on [DATE] with diagnoses including cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of eight sampled residents (Resident 32, 2, and 20) by failing to: 1. Ensure Resident 32 and 2 were given a manual (operated by hand) call bell (a tool placed on a hard surface that rings and is used to get attention) to facilitate communication with staff when the facility call light system (a system consisting of a hand held button connected by a cord to a wall plate; when the button is pressed a light on the wall plate, a light above the resident's door, and a light at the nurse's station alert staff) was not functioning. 2. Ensure Resident 20's call light (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach. This deficient practice had the potential to result in a delay with resident care, and residents not receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of five sampled residents (Resident 48, 54, 198). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure to take Resident 49's blood pressure (BP-measurement of the pressure of the blood pushing against the walls of the arteries) and heart rate (HR) prior to administering metoprolol, lisinopril, and losartan (medications that treat high blood pressure). This deficient practice had the potential to result in unintended complications including hypotension (low blood pressure) and bradycardia (low heart rate). Findings: 1.a. A review of Resident 48's admission Record indicated the facility originally admitted the resident on 5/8/2018 and recently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure licensed nurses did not administer midodrine (used to treat low blood pressure [BP - the force of blood pushing against the walls of your arteries]) outside of the physician's prescribed parameters (specific instructions that can be measured) on multiple dates for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at increased risk of experiencing adverse effects (unwanted undesirable effects related to a medication), such as uncontrolled blood pressure. 2. Ensure enoxaparin sodium (a medication that helps prevent the formation of blood clots [clumps that occur when blood hardens from a liquid to a solid]) was administered per physician's order to rotate injection (the act of administering a liquid drug into a person's body using a needle) sites (location of injection on the body) for one of three sampled residents (Resident 11). This deficient practice had the potential to result in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 49, 54, 198, and 11), by failing to: 1. Ensure Resident 49's vital signs (measurements of the body's most basic functions) were done every shift in accordance with the physician's order. 2. Failing to ensure routine medications were documented in the Medication Administration Record (MAR- a flow sheet where nursing documents medications and services provided to a resident daily) immediately after administration per the facility's policy for Residents 54, 198, and 11. 3. Failing to ensure Fioricet (a combination of the medications butalbital [a medication that causes relaxation], acetaminophen [a medication to treat pain], and caffeine [a stimulant] used to treat pain) was accurately documented for a pain level within the physician's ordered parameters (a guideline for when to administer medication) for Resident 11. These deficient practices placed the residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 42 and 32) investigated for dignity were treated with respect and dignity by: 1. Failing to ensure Resident 42 was addressed by their preferred name during a medication pass observation. 2. Failing to ensure Certified Nursing Assistant 5 (CNA 5) provided Resident 32 with full bodily privacy by failing to ensure the resident's entire right side of her body was not fully exposed while taking the resident from the shower room back to her room. These deficient practices had the potential to negatively affect the resident's sense of self-esteem and self-worth. Findings: 1. A review of Resident 42's admission Record indicated the facility admitted the resident on 11/26/2021 with diagnoses that included hereditary and idiopathic neuropathy (condition that causes numbness, tingling and muscle weakness in the limbs), chronic kidney disease (condition in which the organs that filter blood are damaged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of two sampled residents (Resident 198). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 198. Findings: A review of Resident 198's admission Record indicated the facility admitted the resident on 11/5/2023 with diagnoses that included muscle weakness, anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), presence of right artificial knee joint. A review of Resident 198's History and Physical (H&P- the most formal and complete assessment of the patient and the problem) indicated the resident had the capacity to understand and make decisions. During a concurrent interview and record review on 11/15/2023 at 9:11 a.m., with Registered Nurse 1 (RN1), reviewed Resident 198's care plans dated 11/5/2023-11/15/2023. RN 1 stated that Resident 198 was admitted on [DATE] with multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for two of five sampled residents (Resident 9 and 23) by failing to: 1. Develop a care plan for the use of heparin (anticoagulant [medication that helps prevent blood clots]) for Resident 9. 2. Develop a care plan for the use of Eliquis (anticoagulant) for Resident 23. These deficient practices had the potential for Resident 9 and 23 to not receive the necessary care and services to prevent complications of the anticoagulant therapy such as bleeding. Findings: a. A review of Resident 9's admission Record indicated the facility admitted the resident on 7/24/2023 with diagnoses that included muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), acute kidney failure (a condition in which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and residents received adequate supervision to prevent accidents by failing to ensure staff did not leave residents unattended with the bed in the high position for one of eight sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 sustaining an injury from a fall. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 1/18/2019 and readmitted the resident on 11/1/2021 with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and behavior), restlessness and agitation, muscle weakness, difficulty walking, and history of falling. A review of Resident 2's Minimum Data Set (MDS - an assessment and screening tool) dated 10/17/2023, indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS further indicated the resident was dependent on staff for transfers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for two of five sampled residents (Resident 299 and Resident 300). This deficient practice had the potential for Resident 299 and 300 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 299's admission Record indicated the facility admitted the resident on 11/6/2023 with diagnoses including acute pancreatitis (condition where the pancreas [small organ, located behind the stomach, that helps with digestion] becomes inflamed over a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal (prevents infection from pneumonia [infection that infects one of both lungs]) and/or the influenza (contagious respiratory illness caused by viruses) vaccinations were offered and residents and/or their representatives were educated about the benefits and side effects of the vaccinations for two of five sampled residents (Resident 198 and 298). This deficient practice placed Resident 198 and 298 at a higher risk of acquiring and transmitting pneumonia and influenza to other residents in the facility. Findings: a. A review of Resident 198's admission Record indicated the facility admitted the resident on 11/5/2023, with diagnoses including joint replacement surgery (procedure to remove damaged joint and replace with a new artificial part), difficulty walking, and muscle weakness. A review of Resident 198's History and Physical (H&P) dated 11/7/2023, indicated resident had the capacity to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to screen, educate, and offer the Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) vaccine for two of five sampled residents (Resident 198 and 298). This deficient practice placed Resident 198 and 298 at a higher risk of acquiring and transmitting COVID-19 to other residents in the facility. Findings: a. A review of Resident 198's admission Record indicated the facility admitted the resident on 11/5/2023, with diagnoses including joint replacement surgery (procedure to remove damaged joint and replace with new artificial part), difficulty walking, and muscle weakness. A review of Resident 198's History and Physical (H&P) dated 11/7/2023, indicated resident had the capacity to understand and make decisions. A review of Resident 198's Immunization Record dated 11/5/2023 until 11/14/2023, indicated there were no immunizations recorded in the electronic file. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.