Deer Meadows Rehabilitation Center

Inspectors wroteBased on review of clinical records and interviews with resident and staff, it was determined that the facility failed to ensure one resident with unwanted sexual behavior received adequate supervision to prevent wandering for three resident records reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, review of facility documentation, and interviews with residents and staff it was determined that the facility failed to conduct a complete and through investigation related to potential verbal abuse for one out of two residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical records, interviews with staff, review of facility investigation and review of facility policies, it was determined that the facility failed to ensure that one of nine residents reviewed received proper assistance during transfer from chair to bed, which resulted in a fall incident and a skin tear to the left leg. (Resident R1)Findings Include:Review of facility policy titled, Fall Prevention and Management with a date of January 12, 2023, states, The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining causal factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. [...]

Inspectors wroteBased on review of clinical record, facility documentation, facility policy, and staff interviews, it was determined the facility failed to ensure that all interventions to prevent fall incidents were in place after Resident R48 was transfer into bed, resulting in actual harm to Resident R48 who fell out of bed and sustained a fractured jaw for one of three residents reviewed for falls. (Resident R48)

Inspectors wroteBased on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean and homelike condition in one of eight nursing units (Dementia Unit 2nd floor).

Inspectors wroteBased on observation, review of clinical records, interview with staff and resident, it was determined that the facility failed to ensure that MDS (Minimum Data Set) a federally required resident assessment completed at a specific interval) was completed accurately for one of thirty-five residents reviewed. (Resident R143)

Inspectors wroteBased ln observation and review of clinical record, it was determined that the facility failed to ensure that a baseline care plan was developed within 48 hours of a resident's admission for one of thirty-five residents observed. (Resident R13)

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a person-centered comprehensive care plan related to dementia care and/or activities for one of 35 residents reviewed (Resident R55).

Inspectors wroteBased on a review of clinical records, and interviews with residents, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for one of the four residents reviewed (Residents R153)

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two of eight ([NAME] 2 nursing unit and W1B nursing unit).

Inspectors wroteBased on observation, staff interview and review of clinical records it was determined that the facility failed to ensure that urinary drainage systems were properly positioned and maintained to prevent urine backflow and urinary tract infection for one of ten residents observed with urinary catheter. (Resident R13)Review of facility policy on Catheter-Foley with a review date of July 2025, section Procedure revealed that under section POLICY: this policy provides the procedure to ensure the safe sterile placement and removal of the folly catheter it also provides guidelines for catheter care and specimen collection from the catheter under section PROCEDURE #V. Completing the Procedure: #2. Position the bag to avoid urine reflux into the bladder, kinking or gross contamination of the bag. [...]

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of six residents reviewed (Resident R19).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of three residents observed during medication administration (Resident R137).

Inspectors wroteBased on review of facility documentation, review of clinical records, and resident interviews, it was determined that the facility failed to submit complete and accurate information to the State Survey Agency regarding a resident fall for one of three residents reviewed for facility reported incidents (Resident R48). Findings Include: Review of facility reported incident, dated January 11, 2025, revealed nurse aide was assisting Resident R48 with evening care. After CNA transferred resident to bed she/he took the wheelchair away from the side of the bed towards the door in resident room to make space for her to assist resident with evening care. Resident was placed at center of the bed. Then suddenly she heard the noise and observed the resident lying on the floor. Upon arrival, the charge nurse observed resident lying on the floor beside her bed. [...]

Inspectors wroteBased on interview with staff, review of clinical record and review of facility provided documentation, it was determined that facility did not ensure to maintain clinical records in accordance with professional standards of practice for one of three clinical records reviewed. (Resident R2)

Inspectors wroteBased review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to prevent infection one of 3 residents reviewed for Intravenous Therapy. (Resident R1)

Inspectors wroteBased on observations of the physical environment, interviews with staff and reviews of the pest control operators reports, it was determined that the facility was not maintaining an effective pest control program on one of eight nursing units.

Inspectors wroteBased on review of clinical record, facility policy, and staff and resident interviews, it was determined that the facility failed to provide medications timely, resulting in significant medication error for one of five residents reviewed (Resident R1).

Inspectors wroteBased on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers and prevent development of pressure ulcers for four of six residents reviewed for pressure ulcer. (Resident 53, Resident R90, Resident R277 and Resident R14) Findings Include: Review of facility policy Wound Management Guidelines revised April 1, 2022, revealed residents will receive the appropriate treatment for their skin issues as identified in the type of skin/wound presentation and the indicated treatment and interventions for the identified issues. [...]

Inspectors wroteBased on the review of clinical records, facility investigation, interviews with resident and staff, it was determined that the facility failed to treat residents with respect and dignity related to the right to retain and use personal possessions for one of 35 residents reviewed. (Resident R34) Findings Include: Interview with Resident R34 on November 20, 2024, at 12:15 p.m. stated when he was at the dialysis on November 19, 2024, facility staff searched his room, went through his personal possession, took his over-the-counter medications, and discarded some of the food items that was in the refrigerator in his room without his permission. Resident stated he never had staff search his room or remove his personal possession without permission and he has been a resident of the facility for over on year. Resident stated the search was due to state survey in the facility. [...]

Inspectors wroteBased on observation, interviews with staff and review of facility policy, it was determined that the facility failed to maintain comfortable and safe temperature levels for one of eight units in the facility ( [NAME] Pavilion Second Floor).

Inspectors wroteBased on review of clinical record, observations, and staff interview it was determined that the facility failed to provide nail care for a dependent resident for one of 35 residents reviewed (Resident R18). Findings Include: Review of Resident R18's annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 25, 2024, revealed the resident was cognitively impaired, diagnosed with heart failure, high blood pressure, cerebrovascular accident (Stroke) and dementia. Further review indicated the resident had impairments on both sides of his upper body and was dependent on staff for personal hygiene. Observation of Resident R18 with Licensed Practical Nurse Employee E11 on November 21, 2024, at 10:15 a.m. stated the resident clenches his hands and uses a palm guard because his hands are contracted. [...]

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to implement fall interventions for two of five residents reviewed for falls (Resident R4 and R110). Findings Include: Facility policy titled Fall Prevention and Management (revised January 2023), indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. [...]

Inspectors wroteBased on review of facility policy, observations, review of clinical record, and resident interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident R162). Findings Include: Review of facility Weight Policy revised 04/03/2017, revealed residents should be weighed at least monthly, unless otherwise specified, and that any confirmed weight change should be reported to the physician and registered dietitian for their evaluation and recommendations. Review of Resident R162's care plan revised October 7, 2024, revealed the resident was at risk for alteration in nutrition/hydration. Interventions dated October 7, 2024, included to obtain weights as ordered and monitor PO (by mouth) intake. [...]

Inspectors wroteBased on review of clinical records, review of facility policy, observations, and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for two of four residents receiving oxygen therapy. (Resident R4, Resident R149)

Inspectors wroteBased on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident two of 35 sampled residents (Resident R34 and R106 ).

Inspectors wroteBased on the observations and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the care of urinary catheters and respiratory care equipment for four of 35 residents reviewed. Findings Include: Observation of Resident R135 on November 19, 2024, at 10:32 a.m., revealed that the resident had a urinary catheter. Further observation revealed that the catheter bag was on the floor. Observation of Resident R17 on November 19, 2024, at 10:25 a.m., revealed that resident's oxygen tubing which was connected to oxygen concentrator was lying on the floor without any bag. [...]

Inspectors wroteBased upon observations, interviews, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for two of eight units in the facility ([NAME] Pavilion first and second floor).

Inspectors wroteBased on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: Review of facility procedure titled, Resources dated unknown indicates conduct safety and operation inspections 1. Visually inspect all appliances for damage 2. Inspect electric cords and connections 3. Check Filter hoods above stove 4. Check C02 tank storage containers 5. Test functionality of appliances and proper operation of al controls 6. Lubricate per manufacture's specs as needed. 7. Inspect all tethered gas fed appliances. Document findings in log book 1. Remove damaged items from kitchen use 2. Note any discrepancies 3. Note any service repairs and maintenance in TELS equipment log. [...]

Inspectors wroteBased on review of facility documentation and review of clinical record, it was determined that facility failed to ensure that residents are free of significant medication error related to administration of medications prepared for a different resident. (Resident R1)

Inspectors wroteBased on review of facility policies, facility documents, clinical records review, and resident and staff interviews, it was determined that the facility failed to ensure that residents are free of misappropriation of resident property for one out of 10 residents reviewed. (Resident R1).

Inspectors wroteBased on review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Ground Wing C)

Inspectors wroteBased on review of facility policy, review of clinical records, review of facility documents, staff and family interview, it was determined that the facility failed to uphold the dignity of two of eight residents (Resident R25 and Resident R85) and during dining service for one of eight nursing unit reviewed. ([NAME] 2 nursing unit)

Inspectors wroteBased on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs related to having a bariatric bed and beside chair for 1 out of 35 residents observed. (Resident R41)

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of eight nursing units. ([NAME] 2 Nursing Unit)

Inspectors wroteBased on, review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to supervision needs for one out of eight residents reviewed. (Resident R381)

Inspectors wroteBased on clinical record review and interviews with resident and staff, it was determined that the facility failed to revise the care plan for participation in restorative therapy for one of 35 residents reviewed (Resident R166).

Inspectors wroteBased on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders were followed for two of 35 records reviewed. (Resident R4 and Resident R116)

Inspectors wroteBased on observation, review of resident's clinical record, and interview with staff, it was determined that the facility failed to ensure the appropriate supervision related to risk of aspiration for one of eight residents reviewed. (Resident R 381)

Inspectors wroteBased on observations, review of clinical records and facility policy, and interviews with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of 21 residents reviewed. (Resident R104) Finding Include: Observation of Resident R104 on February 12, 2024, at 10:42 a.m, revealed that the resident was receiving oxygen via nasal cannula from a portable oxygen concentrator (machine). The oxygen was set at 4 liters per minute. This was verified by Employee E2, Registered Nurse Unit Manager. Review of physician orders for Resident R104 on April 16, 2023, revealed an order to administer oxygen at 2 liters per minute via nasal cannula continuously. Interview with Employee E12, on February 12, 2024, at 10:42 a.m. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to provide appropriately textured foods to meet the needs of residents on a mechanically altered diet for one of 22 residents observed during dining (Resident R158). Findings Include: Review of the clear liquid diet guidelines from the facility's diet manual revealed the diet consists of foods that are clear and liquid, or that becomes liquids at room or body temperature. The diet contains no milk or milk products. Review of Resident R158's physician order dated January 25, 2024, revealed the resident was ordered a clear liquid diet. Continued review of Resident R158's physician orders revealed an order dated October 15, 2023, to provide a pureed snack at bedtime. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with food safety standards for one of eight nursing unit pantry's ([NAME] 1). Findings Include: Review of facility policy Pantry Refrigerator, revised September 2021, revealed pantry refrigerators will be monitored on a routine basis to ensure food safety. Refrigerator temperatures will be maintained at 32 to 41 degrees Fahrenheit and freezer temperatures will be maintained at 0 to less than or equal to -10 degrees Fahrenheit. Further review of facility policy revealed refrigerators will be checked on a routine basis for cleanliness and cleaned monthly or as needed. [...]

Inspectors wroteBased on interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to ensure one resident who concent to received the Covid -19 vaccine was provided the vaccine in a timely manner for one of 35 resident records reviewed (Resident R166).

Inspectors wroteBased on observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for one resident and four resident rooms of two floors (Second floor dining room and First Floor Rehab). Finding Include: Interview with Resident R116 on February 12, 2024, at 10:27 a.m. stated his wheelchair leg rest was broke and part of the leg rest was missing foot pad. He stated it was like that for almost four months. Observation of Resident R116's wheelchair revealed that the left side leg rest was missing foot pad which exposed sharp metal edges. Wheelchair also had white color substance underneath the seat on the metal frame appeared like dust and cobb [NAME]. Observation of resident rooms 208, 209 and 210 revealed that there was window air-condition unit on the windowsills. [...]

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Manual, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments accurately reflected residents' cognitive status for 3 of 35 residents reviewed (Residents R158, R64, and R66). Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care RAI Manual dated October 2019 revealed the resident Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) included Section C: Cognitive Status which is used to determine the resident's attention, orientation, and ability to registry and recall information. Review of Resident R158's clinical record revealed a Quarterly MDS dated [DATE]. [...]