Meadows Of Leipsic

Based on review of facility's Legionella plan and documentation, staff interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to develop and implement a comprehensive and effective infection control/water management plan to prevent the risk of Legionella. This had the possible affect all residents in the facility. The facility census was 44.Findings include:Review of the facility's Legionella Water Management Plan, updated 08/04/25, revealed Legionella could grow and spread in common areas including sinks, showers, water fountains, standing water on washing tables, spa tub and ice machines. There were no records of flushing of low-flow or dead-leg pipes by the facility. The facility had a written description of the building's water system but failed to have a flow diagram.Interview on 01/22/26 at 2:22 P.M. with the Administrator verified the facility did not document or complete flushes of the dead-leg and low flow areas. The facility did not complete a flow diagram. The Administrator stated their policy said they did not have 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 record review, observation, resident interview, and staff interview, the facility failed to ensure resident requests for bed accommodations were honored. This affected one (Resident #4) of two residents reviewed for accommodation of needs. The facility census was 44. Findings Include:Review of Resident #4's medical record revealed an admission date of 10/22/24. Diagnoses included fracture of right femur (subsequent encounter) with orthopedic surgery, type I diabetes mellitus, osteoporosis, anxiety disorder, chronic pain, and muscle weakness.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Resident #4 was independent with toilet use, bed mobility, transfer, and required set up assistance with bathing. Resident #4 displayed no behaviors during the review period. Review of Resident #4's care plan revised 01/20/26 revealed supports and interventions for behaviors of hyper fixation on condition bed frame and mattress (12/09/25). Interventions included…

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 medical review, observation, and staff interviews, the facility failed to ensure the resident's bed sheets were clean and sanitary. This affected one (Resident #50) of 21 residents reviewed for clean and homelike environment. The facility census was 44.Findings include:Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including acute kidney failure with tubular necrosis, dementia, and obstructive and reflux uropathy,The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had impaired cognition. Resident #50 was dependent with toileting. Observation on 01/22/26 at 10:07 A.M. of catheter care revealed Resident #50 had a bowel movement at the start of catheter care. The Director of Nursing (DON) and Certified Nursing Assistant (CNA) #584 completed incontinence care on Resident #50. There was fecal matter on the lift sheet due to CNA #584 wiping across lift sheet with fecal matter on it. Lift sheet was not changed and the soiled lift sheet remained under…

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, record review, and resident and staff interview, the facility failed to timely assess and obtain a physician order to treat the resident's wounds. This affected one (Resident #21) of three residents reviewed for skin conditions. The facility census was 44. Findings include:Review of Resident #21's medical record revealed an admission date of 11/10/23. Diagnoses included heart failure, sepsis, obesity, acquired absence of right leg above the knee, convulsions, depression, type II diabetes, and peripheral vascular disease. Review of Resident #21's care plan revised 11/30/25 revealed supports and interventions for self-care deficit, risk for excessive bleeding and bruising related to medications, risk for injury related to seizures, pain, and risk for skin breakdown. Interventions for risk for skin breakdown included weekly skin assessments, keep linens clean and dry, and avoid shearing skin during positioning, turning and transferring. The Minimum Data Set (MDS) assessment dated [DATE]…

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, staff interview, and policy review, the facility failed to ensure dietary staff were provided beard protectors while working in the kitchen. This affected all 39 residents who resided in the facility and received food from the kitchen. The facility census was 39. Findings include: Observation on 05/30/23 at 8:27 A.M. revealed [NAME] #205 had a full beard and mustache approximately one inch long and was working in the kitchen. The [NAME] was not wearing a beard protector. Interview with [NAME] #205 on 05/30/23 at 8:32 A.M. verified that he did not wear a beard protector while working as they were not provided for staff. Interview with the Director of Food Services on 05/30/23 at 8:35 A.M. revealed the facility did not have beard protectors in stock and she would look into purchasing. Review of the facility policy titled, Hair Restraint, dated 11/30/21 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from…

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 medical record review, observation, and staff interview, with facility failed to ensure residents received adequate and timely assistance with grooming. This affected one (Resident #1) of two residents reviewed for activities of daily living. The facility census was 39. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic kidney disease stage 4, acute kidney failure, hypertensive heart disease with heart failure, contracture left and right hand, hypothyroidism, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 required total dependence for personal hygiene. Review of the care plan dated 02/13/17 revealed Resident #1 needed support of staff for activities of daily living (ADLs) completion and interventions included to provide assistance for ADLs. Further review of the medical record revealed no documentation showing…

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 medical record review, observation, and staff interview, the facility failed to apply hand splints as ordered and failed to implement interventions for a resident with bilateral hand contracture's. This affected one (Resident #15) of one resident observed for the use of hand splints. The facility's census was 39. Findings include: Review of Resident #15's medical record revealed an admission date of 03/20/17. Diagnoses included cerebral palsy, intellectual disabilities, and phalanax fracture. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was rarely understood and had impairments of the bilateral upper extremities. Review of Resident #15's most recent care plan revealed interventions to follow physical therapy and occupation therapy orders. Resident #15 was to have rolled up washcloths (one washcloth for each hand) in each palm/hand to decrease tightness and skin breakdown. The resident was to use washcloths when in bed (at night and during any naps during…

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 medical record review, review of the meal ticket, review of the menu, observation, and staff interview, the facility failed to ensure diets were provided as ordered. This affected one (Resident #1) of one resident reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic kidney disease stage 4, acute kidney failure, hypertensive heart disease with heart failure, hyperlipidemia, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of Resident #1's care plan dated 08/16/21 revealed interventions in place to follow diet as ordered by physician as protein, sodium, potassium and phosphorous intake may need to be regulated based on kidney function. Review of the dietician progress note dated 05/17/23 revealed Resident #1 continued on a regular, regular/thin diet with double portion…

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 medical record review, observation, staff interviews, and facility policy review, the facility failed to ensure appropriate signage was placed on the door of one Resident (#20) in quarantine status, and failed to ensure one Resident (#13) remained in quarantine status. This had the potential to affect all 43 residents of the facility. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 01/31/17. The resident had a hospital stay from 04/17/21 through 04/24/21. Observation on 04/26/21 at 11:59 A.M. revealed there was no sign on the resident's door to indicate transmission-based precautions. Interview on 04/26/21 at 12:05 P.M. with Registered Nurse (RN) #401 verified Resident #20 had been on transmission-based precautions due to having a hospital stay and the resident's door did not have signage. Review of facility policy titled COVID-19 Guidelines for Contact/Droplet Precautions, dated 07/29/20, revealed when a resident is on contact/droplet precautions a sign is posted on the resident's door alerting of precautions. 2. 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 medical record review, observation, staff interview, and facility policy review, the facility failed to ensure a resident's call light was within reach. This affected one Resident (#23) of 14 observed for call lights. The facility census was 43. Findings include: Review of the medical record for Resident #23 revealed an admission date of 11/22/20 with diagnoses including chronic kidney disease with heart failure, type 2 diabetes mellitus, history of falling, and chronic obstructive pulmonary disease (COPD). Review of Resident #23's care plan dated 05/23/20 revealed Resident #23 had impaired ability to perform Activities of Daily Living (ADLs) tasks and needed staff support to complete. Resident #23 was at risk for falling related weakness, impaired safety awareness, and use of medication. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 had mild cognitive impairment. The resident was noted to require a one person physical assist with bed mobility, extensive…

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 medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure one Resident (#15) of one reviewed was provided proper interventions to potentially prevent constipation. The facility's census was 43. Findings include: Medical record review for Resident #15 revealed an admission of 11/17/20. Diagnoses included, multiple fractures of ribs, type II diabetes, atrial fibrillation (irregular heartbeat), and constipation. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #15's orders revealed orders for GlycoLax 17 grams, once per day, as needed (PRN) with a start date of 11/17/20, Colace 100 milligrams (mg) two times a day with a start date of 02/12/21, and Miralax 17 grams once per day with a start date of 03/25/21. Review of Resident #15's Bowel and Bladder by Shift Chart revealed from 02/06/21 to 02/11/21 (six days) Resident #15 had no bowel movement documented.…

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 medical record review, resident interview, and staff interview, the facility failed to ensure one resident was free from falls when personal care was provided by one staff member, instead of the required two. This affected one Resident (#10) of three reviewed for falls. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admission date of 11/13/20 with diagnoses including, type II diabetes, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed she had a fall during incontinence care. Resident #10 revealed a State Tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10 could not recall the date of when the incident happened.…

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 medical record review, resident interview, staff interview, and facility policy review, the facility failed to accurately document an incident/fall in a resident's medical record. This affected one Resident (#10) of one reviewed for accurate documentation. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admission date of 11/13/20 with diagnoses including, type II diabetes, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Review of Resident #10's progress notes for February 2021 and March 2021 revealed no evidence of any documentation of incidents or falls. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed a State Tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10…

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 medical record review, observation., staff interview, and review of facility policy, the facility failed to ensure proper maintenance was completed on a wheelchair being used by one Resident (#16) of one observed. The facility census was 43. Findings include: Review of Resident #16's medical record revealed an admission date of 11/20/20 with diagnoses including unspecified cerebrovascular disease (stroke), heart failure, and history of falling. Observation on 04/27/21 at 11:51 A.M. revealed Resident #16 was sitting in her wheelchair. There were two screws exposed on the right arm rest of the wheelchair protruding through the foam padding. The exposed screws were approximately one inch long. Interview on 04/27/21 at 11:55 A.M. with Registered Nurse (RN) #405 verified Resident #16's wheelchair had exposed protruding screws on the right arm rest of the wheelchair. Review of facility policy titled, Guidelines for General Use of Equipment, dated 08/01/16 revealed, the facility provides and maintains routine equipment for the general use for the resident population.