Country Meadows

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders when residents missed doses of medication due to being unavailable for six residents (Resident #1, #2, #3, #4, #5, and #6) out of six sampled residents. The facility's census was 68. The facility did not provide a policy regarding following physician orders or regarding residents missing doses of medications.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for two residents (Resident #3 and #44) out of 16 sampled residents and one resident (Resident #65) outside the sample. The facility's census was 65. The facility did not provide a policy regarding MDS accuracy. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2024, showed:- J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services;- O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center, failed to ensure physician orders were in place, and failed to assess and monitor the dialysis site for one resident (Resident #18) out of one sampled resident receiving dialysis. This failure had the potential to result in unmet needs or complications related to dialysis care. The facility census was 65. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #40 and #51) out of 15 sampled residents. The facility census was 60. Review of the facility's policy, Resident Assessment Instrument (RAI) General Guidelines, undated, showed: - Completion of the RAI process: Accurate and timely completion of MDS and Care Area Assessments (CAA) areas as assigned; - Accurate completion requires resident interviews, staff interviews, resident assessment, review of the clinical record including physician notes, and observation of the resident in the nursing home environment. Review of the RAI Manual, revised October 2023, showed: - A1805: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for four residents (Resident #3, #21, #34, and #36) out of 15 sampled residents and one resident (Resident #174) outside the sample. The facility's census was 60. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #3's medical record showed: - An admission date of 10/12/22; - Diagnoses of dysphagia (difficulty swallowing foods or liquids), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations); - An order for biotin (B vitamin) 10 milligrams (mg), one tablet daily, dated 01/25/24; - An order for Namzaric (dementia medication) 28-10 mg, one capsule daily at bedtime, dated 01/25/24; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain proper infection control practices during perineal care (washing the genital and rectal areas of the body) for two residents (Resident #14 and Resident #46) outside of the 15 sampled residents. The facility's census was 60. Review of the facility's policy, Gloves, dated March 2015, showed: - Wear gloves when anticipating that hands will be in contact with mucous membranes, non-intact skin, and body substances such as blood, urine, feces, drainage, oral secretions, vomit, or items soiled with these substances; - Gloves must be changed between residents and between contact with different body sites of same resident; - Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to skin; - Handling medical equipment and devices with contaminated gloves is not acceptable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility's census was 63. Record review of the facility's Receiving and Storage of Food policy, dated April 2006, showed: -The dietary manager is responsible for receiving and storing food and nonfood items; - A table of safe temperatures for refrigerators and freezers (frozen food should be kept at -10 to 0 degrees Fahrenheit); -The policy did not address freezer cleaning/maintenance. Record review of the dietician's monthly kitchen recommendations showed: -On 8/22/22, door to freezer continues to not fully close due to significant ice build up; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility for two residents (Resident #22 and #45) out of 16 sampled residents. The facility's census was 63. The facility did not provide an MDS policy. 1. Record review of Resident #22's medical record showed: - An admission date of 12/19/19; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and shortness of breath; - An order for oxygen two to four liters per minute per nasal cannula continuous during hours of sleep, dated 11/29/22; - An order for oxygen two to four liters per minute per nasal cannula as needed for shortness of breath, dated 12/19/2019; [...]

Inspectors wroteBased on record review and interview, the facility failed to include the infection preventionist in quarterly quality assessment and assurance (QAA) meetings. The facility's census was 63. 1. Record review of the first quarter QAA Committee sign in sheet, dated 4/13/22, and the second Quarter QAA Committee sign in sheet, dated 7/27/22 showed the following members attended: - Administrator; - Medical Director; - Director of Nurses (DON); - Assistant Director of Nurses (ADON); - Social Services Director (SSD). Record review of the third quarter QAA Committee sign in sheet, dated 10/12/22, showed the following members attended: - Administrator; - Medical Director; - Director of Nursing; - Assistant Director of Nursing. During an interview on 12/16/22 at 11:09 A.M., the Administrator said QAA meets every three months and the DON, ADON, Administrator, and Medical Director attend the meetings. [...]