Country Meadow Rehabilitation And Nursing Center

Based on record review and interview, the facility failed to provide the resident council with responses and action regarding their concerns regarding activities. This affected five residents (Resident #3, #5, #20, #27 and #36) who regularly attend council meetings and had the potential to affect all residents. The facility census was 38. Findings include: Review of the facility resident council meeting minutes from 11/22/23 to 05/14/24 revealed the residents had voiced the following concerns related to activities during resident council meetings: a. At the resident council meeting held 11/22/23 , residents voiced concerns regarding knowing when activities are held, and where activity calendars were placed in their rooms. Residents requested more physical activities and more variety of activities. Listed action taken included giving reminders throughout the day and adding more variety to the calendar. There was additionally a concern with bingo candy raised, with the action taken including AD #88 speaking to the administrator about bingo candy. The Administrator's recorded written…

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, record review, interview and policy review, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the resident preferences and failed to ensure activities were scheduled on evenings and weekends. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of the Activity Participation Logs for March 2024, April 2024, and May 2024 revealed all residents had their own log for each month, on which residents' activity participation was logged. Residents were recorded as participating in activities, based on the date, and participation was logged as active, passive, or refusal to participate. The logs consistently were blank for Saturdays and Sundays, indicating no participation in activities. During an interview on 05/28/24 at 9:19 A.M., Resident #14 stated there used to be activities on the weekend but there are no longer. The resident stated he felt like he was in jail as there was nothing to do. During an interview on 05/28/24 at 9:26…

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 personnel record review, staff interview, and review of the facility activity director job description, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of Activity Director (AD) #88's personnel record revealed a hire date of 10/04/23. AD #88 signed the Activity Director job description on the date of hire, which listed primary functions and responsibilities of then position which included planning, scheduling, and implementing a program of individual and group activities based on the residents' schedule, plan and implement evening and weekend functions as necessary, and recruit, schedule and supervise assistants and volunteers, and maintain an activity attendance record for each resident. The section on Education/Experience, noted as to be completed by the facility, was blank. AD #88's personnel record contained no evidence of formal training in an activities or therapeutic recreation program or…

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 record review, observation, interview and record review, the facility failed to ensure proper ware washing and failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 38 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 38. Findings include: During a tour of the kitchen on 05/28/24 at 7:49 A.M., the reach-in freezer contained frozen fruit and waffles that were out of their original package and were not labeled or dated. In the dry storeroom, there was a can of baked beans and a can of sliced apples that were dented and were not separated from the other canned goods. Dietary Manager (DM) #55 verified observations on 05/28/24 at 8:10 A.M. DM #55 stated that he did not know that dented cans needed to be separated. During observation on 05/29/24 at 8:30 A.M., Dietary Aide (DA) #40 check for the chlorine concentration of the dish machine and it was not registering any sanitizer. The dish machine was repaired and on 05/29/24 at 9:50 A.M., registered 50 ppm 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 record review, interview and policy review, the facility failed to ensure quarterly care conferences were held and the resident and/or their representative were invited to participate. This affected one (Resident #04) of twelve screened for participation in care planning. The facility census was 38. Findings include: Review of the medical record for Resident #04 revealed an admission date of 06/19/22. Medical diagnoses included paranoid schizophrenia, neuroleptic-inducted parkinsonism, and epilepsy. Review of Resident #04's Minimum Data Set (MDS) annual assessment, dated 04/02/24, revealed the resident had severely impaired cognition. Review of Resident #04's interdisciplinary care conference notes revealed care conferences were held on 04/20/23, 07/27/23, and 10/19/23. Each care conference note indicated the care conferences were only attended by a Registered Nurse (RN) and a Social Services Designee (SSD). An interview on 05/28/24 at 1:35 P.M. with a family member of Resident #04 revealed the facility only held care conferences approximately once a year and she could not…

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 policy review, the failed to ensure a resident refrigerator was clean and that food items were labeled and dated. This had the potential to affect all 35 residents residing at the facility. Findings include: During observation on 06/06/22 at 4:35 P.M. , the refrigerator located in the medication storage room was full of undated and unlabeled food items. The refrigerator had a foul odor. The Director of Nursing (DON), present during the observation, stated the refrigerator held resident food items. Food items include a prepared meal with the store print enjoy by 5/25/22 with no name; a Tupperware bowl and lid with a white liquid that had no name and no date; a plastic bag of bagels that was stuck to the refrigerator shelf that had no name and no date; a half stick of butter that was unwrapped with no name and no date; deli lunch meat that appeared slimy and was dated 5/26/22 with no name; a plastic bag of cobbler undated and with no name; a plastic bag of ham dated 05/13/22 with no name; a plastic bag of cooked bacon, undated with no name; a piece…

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 treat residents with dignity and respect. This affected two (Residents #30 and #6) of two residents reviewed. The facility census was 35. Findings include: 1. Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance for activities of daily living. Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. Resident #30 required set up help of one for meals. Resident had no verbal or physical behaviors exhibited including rejection of care. Resident #30's hearing was adequate and vision…

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, record review and review of the facility policy, the facility failed to investigate and report an injury of unknown origin. This affected one (Resident #30) of one resident reviewed. The facility census was 35. Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnosis included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance of two for bed mobility and transfers, Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. During interview on 06/06/22 at 9:18 A.M., Hospice Registered Nurse (RN) #847 revealed Resident #30 had bruises on both of her upper arms. Hospice Nurse RN #847 stated…

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, record review and policy review, the facility failed to perform incontinence care on a resident. This affected one (Resident #30) of one resident reviewed for incontinence care. The facility census was 35. Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident #30 was occasionally incontinent of urine and frequently incontinent of bowel and required total dependence of one for toilet use. Review of the care plan dated 04/14/22 revealed Resident #30 had mixed bladder incontinence related to dementia. Interventions included to toilet every two hours and as required for incontinence. Wash, rinse and dry perineum after incontinent episode. Ruing observation on 06/07/22 at 9:15 A.M., State Tested Nursing Assistant (STNA) #846 and #824 stood Resident #30 up 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.

Based on observation and staff interview, the facility failed to ensure medications were stored in a secured manner. This affected the 14 residents (Residents #10, #14, #16, #20, #21, #28, #31, #33, #34, #36, #37, #38 and #40) who resided on the birch unit of the facility and one of two medication carts observed. The facility census was 40. Findings Include: Observation of the birch hall nurse's medication cart on 05/19/19 between 9:36 A.M. and 9:49 A.M. with Licensed Practical Nurse (LPN) #300 revealed six unidentified loose pills at the bottom of multiple drawers through out the medication cart. LPN #300 verified the findings at the time of discovery. Review of the facilities policy entitled Storage of Medications, revised April 2007, revealed Drugs shall be stored in an orderly manner in cabinet, drawers, carts or automatic dispensing systems. The facility identified 14 residents (Residents #10, #14, #16, #20, #21, #28, #31, #33, #34, #36, #37, #38 and #40) who resided on the birch unit and had medication in the cart observed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the resident's had updated care plans reflecting catheter care for Resident #12 and care of a tracheostomy stoma site for Resident #7. This affected two residents (Resident #7 and Resident #12) of 12 residents who were reviewed for accurate care plans. The facility census was 40. Findings Include: 1. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder and chronic kidney disease. The resident was admitted with a urinary catheter in place. Review of the quarterly Minimum Data Set Assessment (MDS) assessment, dated 03/31/19, revealed Resident #12 was cognitively intact and had a urinary catheter in place. Review of the physician orders, dated 06/26/18, revealed the physician ordered for urinary catheter care to be done every shift. Review of the resident's plan of care dated 06/18/18 showed that this…

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.