Fair Meadow Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess for ability or safety and then care plan the self-administration of medication for 1 of 1 resident (R36) observed to have medication prepared by staff and then left with him to take on his own. Findings include: R36's admission Minimum Data Set (MDS) assessment dated [DATE], identified R36 had intact cognition. Diagnoses included disorder of the circulatory system, aneurysm of iliac artery and lower extremity and chronic obstructive pulmonary disease (COPD). R36's care plan with last review date 9/3/25, identified R36 admitted to the facility on [DATE]. A focus for altered respiratory status was identified with difficult breathing at times. Interventions included to administer medications and puffers as ordered. However, the care plan lacked any evidence R36 had been assessed or approved to administer nebulized medications independently. On 9/9/25, at 3:33 p.m., licensed practical nurse (LPN)-A prepared R36'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 document review, the facility failed to ensure a defined perimeter mattress (DPM) was not used in a manner to restrain residents while in bed for 1 of 3 residents (R14) reviewed for restraints.Findings include:R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had a severe cognitive impairment, diagnoses that included bipolar disorder, epilepsy, and vascular dementia and identified R14 used an other restraint while in bed daily.R14's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 1/31/25, identified R14 had impaired cognitive function/impaired thought processes related to dementia. R14's cognitive assessment indicated severe impairment. R14 was able to make her needs known and was understood and understood others.R124's Behavioral Symptoms CAA dated 1/31/25, identified R14 had a potential to demonstrate behaviors related to vascular dementia, bipolar disorders, a history of depression with psychosis, and a generalized anxiety disorder. Behaviors…

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 document review, the facility failed to ensure interventions for safe transfers were implemented for 1 of 5 residents (R23) observed during staff assisted transfers. Findings include:R23's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R23 required maximal assistance with transfers and ambulation. Diagnoses included depression, hypertension, osteoporosis, osteoarthritis, muscle weakness, and low back pain. R23's care plan with review date 8/20/25, identified R23 had a self-care performance deficit and a goal was listed to maintain her current level of function in all activities of daily living (ADLs) and mobility. Interventions included to transfer with maximal assist of one and a full wheeled walker with all transfers and to ambulate with moderate assist of one with FWW, gait belt and wheelchair to follow in the hallways. On 9/9/25, at 2:30 p.m. R23 was observed seated in her wheelchair in a common area near the nurse's station.…

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 document review, the facility failed to ensure a physician order for indwelling urinary catheter for 1 of 1 residents (R21) reviewed for urinary catheter. Findings include:R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had a moderate cognitive impairment and diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract making it difficult to urinate), dementia, and benign prostatic hyperplasia (BPH) (an enlarged prostate). R21 used an indwelling urinary catheter.R21's physician order dated 6/8/22, directed to change foley catheter every 90 days. However, the physician order failed to identify type or size of urinary catheter.R21's care plan revised 12/27/23, identified R21 used an indwelling urinary catheter for obstructive uropathy and BPH. R21 required staff assistance with catheter care and emptying of the urinary bag. R21 used a 16 French (fr) urinary catheter with a 10 milliliter (ml) balloon.During an observation…

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 document review, the facility failed to ensure long term residents received routine physician visits consistently every 60 days as required for 1 of 5 residents (R2) reviewed for unnecessary medications.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses that included atrial fibrillation (irregular heartbeat), major depressive disorder, morbid obesity and lymphedema (tissue swelling).R2's medical record identified R2 was evaluated by a medical provider on 8/13/24, 11/19/24, 1/14/25, 2/26/25, 4/15/25, 6/11/25 and 8/29/25.During an interview on 9/10/25 at 1:44 p.m., licensed practical nurse (LPN)-D stated she was responsible to ensure residents were evaluated by a medical provider every 60 days. R2 was not seen timely and LPN-D stated she did not have an explanation why. LPN-D stated she keeps a handwritten schedule every month with the provider schedules, and which residents needed evaluation. However, LPN-D disposed 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.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders which resulted in a medication error rate 9.09% (percent) for 1 of 7 residents (R11) observed to receive mediations during the survey.Findings include:R11's Order Summary Report, dated 8/28/25, identified R11's current physician-ordered medications and treatments. This included an order for potassium chloride extended release 10 milliequivalent (meq) by mouth two times per day, and vitamin D3 25 micrograms (mcg) give two tablets by mouth in the morning, both with start dates 8/26/25. On 9/10/25, at 9:23 a.m. registered nurse (RN)-B prepared R11's medications at a mobile medication cart in the hallway by the nurses' station. RN-B reviewed R11's electronic Medication Administration Record (MAR) which outlined the same order for potassium and vitamin D3 as listed on R11's Order Summary Report (dated 8/26/25). However, RN-B removed an opened bottle of potassium chloride 10 meq tablets and placed two tablets into the medication cup with…

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 document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 3 of 3 residents (R10, R21, R39) who were displaying COVID-19 symptoms.Findings include:The facility NON-COVID Illness tracker dated August 2025, identified the following: unit, resident name, room number, infection type, body of infection, diagnostics, treatment, transmission-based precautions and illness resolution. The tracker also identified the following: On 8/2/25, R39 exhibited a runny nose, cough, and slight sore throat. R39's rapid antigen COVID-19 test was negative and R39 with provided comfort for his symptoms. However, the tracker failed to identify if R39 had a confirmatory negative rapid antigen test and/or was placed into…

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 document review the facility failed to thoroughly investigate an allegation of neglect of care for 1 of 3 residents (R1) reviewed for safety during staff assisted transfers with a mechanical stand device. Findings include: R1's admission Record identified an admission date of 1/17/22. Diagnosis included multiple fractures of pelvis, osteoarthritis in left hip and disorder of bone density. R1's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition. The MDS indicated R1 had lower extremity impairment on both sides and was dependent on staff for transfers. Facility incident report dated 10/5/24, indicated staff nurse responded to a call and found R1 on the bathroom floor with legs stretched forward and her back leaning against staff member's leg. When asked the nursing assistant (NA) stated she had been transferring R1 to the toilet when R1 slipped out of the harness strap and sat on the floor. NA- also stated R1 hit her head during the fall. R1 verbalized having…

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 document review, the facility failed to provide education on immunizations per Center for Disease Control and Prevention (CDC) guidance for 3 of 5 residents (R15, R22, R24) reviewed for immunizations. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE] identified they were [AGE] years old with a diagnosis of a history of COVID-19. R15's immunization record dated 8/27/24, identified pneumococcal polysaccharide vaccine (PPSV23) was given on 7/18/05, and the pneumococcal conjugate vaccine (PCV13) on 4/6/16. R15's medical record did not include evidence R15 or R15's representative received education regarding pneumococcal vaccine booster and there was no indication R15 was offered the pneumococcal vaccine per CDC guidance. R22's significant change MDS dated [DATE], identified they were [AGE] years old with diagnosis of chronic pulmonary edema (fluid in the lungs). R22's immunization record dated 8/27/24, identified pneumococcal polysaccharide vaccine (PPSV23) was given 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and document review, the facility failed to ensure a comprehensive reassessment was completed to ensure seat belt use was still warrented for identified medical symptoms; and failed to release the seatbelt according to care planned interventions for 1 of 1 residents (R9) reviewed for restraints. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had a severe cognitive impairment, had diagnoses that included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions. R9 used a chair that prevented rising every day, and did not identify a trunk restraint. R9 used antipsychotic and antianxiety medications. R9's care plan revised 6/19/22, identified R9 required use of physical restraints: seat belt in a tilt-in-place wheelchair for positioning related to Alzheimer's dementia and R9 leaned forward in her wheelchair. Fall at home prior to admit with Fracture. R9 was continually reaching to her feet or leaning over in wheelchair attempting…

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 comprehensively assess and develop interventions for safety while using a golf cart off campus for 1 of 1 (R23) resident reviewed for safe use of a motorized golf cart. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognition and was independent or needed supervision with activities of daily living (ADL). R23 had upper extremity impairment on one side and no lower extremity impairment. R23's diagnoses included Parkinson's disease with dyskinesia (mild to severe uncontrolled muscle movements). R23's progress notes dated 2/26/24 through 8/27/24, identified multiple occasions of R23 independently leaving the facility on his golf cart and driving to appointments, town, the store, and other activities. The notes identified the resident kept his cell phone on his person, however, the notes failed to identify if R23 was safe while driving the golf cart. R23's medical record lacked an assessment…

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 document review, the facility failed to use personal protective equipment and follow hand hygeine guidelines for a resident known to have a multi-drug resistant organism (MDRO) for 1 of 1 residents (R5) reviewed for activities of daily living (ADLs). Findings include: The Centers for Disease Control and Prevention (CDC) Transmission-Based Precautions dated 4/3/24, identified Transmission-Based Precautions were the second tier of basic infection control and were used in addition to Standard Precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions were needed to prevent infection transmission. Recommendations detailed the use of contact precautions for residents with known or suspected infections that represented an increased risk for contact transmission; wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment; and donning personal protective equipment…

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 document review the facility failed to implement antibiotic stewardship for 1 of 3 residents (R31) reviewed for appropriate use of antibiotics. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. A diagnosis of chronic kidney disease stage 4 was identified. R31's progress notes from 5/3/23 to 5/16/23 identified the following: - 5/3/21, R31 complained of burning with urination. Medical doctor (MD) was notified. - 5/4/23, received orders for a urinary analysis (UA) lab test to be done - 5/5/23, UA lab was collected and sent for analysis and culture. Will await results and update MD - 5/6/23, Order received from MD for Fosfomycin tromethamine (a medication for urinary tract infections (UTI). The medication did not arrive on Friday from the pharmacy, and they would follow up with the pharmacy on Monday. There were no other progress notes regarding R31's UTI or ordered medications. The facility's antibiotic stewardship tracking from May…

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.