Glen Meadows Retirement Com.

Inspectors wroteBased on observation and interview with facility staff, it was determined the facility failed to: 1) ensure expired food items were discarded 2) ensure the ice machine's filtration cartridge was replaced timely and 3) ensure required temperature levels were consistent for dishwashing sanitization. These deficient practices have the potential to affect all facility residents.

Inspectors wroteBased on staff interviews, review of pertinent documentation, and survey findings, it was determined that the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify quality concerns and have a system in place to correct identified concerns. This was found to be evident while conducting the facility's recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to revise the interdisciplinary care plan to meet the residents' needs. This was evident for 1 (Resident #28) of 19 residents reviewed during the re-certification survey process.

Inspectors wroteBased on medical record review and interviews with staff, it was determined that the facility staff failed to develop a baseline care plan and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 1 (Resident #15) of 12 residents reviewed for care plans during the re-certification/complaint survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to update a person-centered care plan for a resident who was wearing a safety device to help prevent them from leaving the facility unattended. This deficient practice was evidenced in 1 (Resident #86) of 3 resident records reviewed for WanderGuard care plans during the revisit survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined the facility failed to implement measures to prevent pressure ulcer development and improvement on the right heel of a resident. This was evident for 1 (Resident #5) of 16 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to have a system to monitor and respond to changes in residents' weights. This was evident for one (Resident #21) of 1 resident reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to provide behavioral health monitoring to ensure a resident's highest practicable mental and psychosocial wellbeing. This was found to be evident for 1 (Resident #8) out of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on a review of the resident medical records and interview with facility staff, it was determined that the facility failed to ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This was evident for 1 ( Resident #84) out of 2 residents reviewed for administration of narcotic medication during the recertification/complaint survey.

Inspectors wroteBased on a review of medical records and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was true for 1 (Resident # 13) of 5 residents reviewed for unnecessary medication review during the recertification/complaint survey.

Inspectors wroteBased on review of facility records and interview with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assessment and Assurance (QAA) meetings.

Inspectors wroteBased on interviews with facility staff and a review of resident records, it was determined that the facility failed to 1) ensure that each resident was offered an influenza immunization during an active flu season and 2) monitor/document each eligible resident's pneumococcal vaccine status. This was evident for 2 (Residents #15 and #84) of 5 residents sampled for immunization review during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to ensure employees' COVID-19 vaccination status. This was evident for 1 (Registered Nurse, RN #14) of 5 employees' immunization records reviewed during the recertification/complaint survey.

Inspectors wroteBased on review of pertinent documentation and interview with staff it was determined that the facility failed to have a transfer agreement with a local hospital. This was found to be evident during the extended survey.

Inspectors wroteBased on review of medical records and other pertinent documentation, interview with facility staff, and observations, it was determined that the facility failed to have an effective system in place to prevent residents with cognitive impairments from leaving the facility without appropriate supervision. This failure led to 1) Resident #16, who was known to have exit-seeking/elopement behaviors with previous two elopement incidents, found outside of the building on 12/13/24 around 6 PM, and 2) Resident #20, who had a wanderguard placed due to high risk of elopement since May 2024, found in the Assisted Living (AL) library on 3/20/25 around 9 AM. This was evident for 2 of 5 reported elopement incidents reviewed during this annual survey. The above findings for Residents #16 and #20 were identified as Immediate Jeopardy on 3/25/25 at 7:45 PM. [...]

Inspectors wroteBased on review of the facility's investigation file and medical records and interview with facility staff, it was determined that the facility failed to ensure a resident remained free of abuse. This was evident for 1 (Resident #18) of 4 residents reviewed for abuse during the recertification/complaint survey.

Inspectors wroteBased on review of facility reported incidents, record review, and interview with staff, it was determined that the facility failed to timely report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (Resident #18 and #11) of 4 residents reviewed for abuse during the recertification/complaint survey.

Inspectors wroteBased on review of facility reported incidents, medical record review, and interview with facility staff, it was determined that the facility failed to thoroughly investigate 1) an allegation of abuse by failing to perform an assessment of the alleged victim, 2) an elopement, and 3) failed to follow through on appropriate corrective action to prevent further instances of medication errors. This was evident for 3 (Resident #11, Resident #16, Resident #85) of 19 residents reviewed during the recertification/complaint survey process.

Inspectors wroteBased on interviews with facility staff and review of resident medical records and the facility incident report, it was determined that facility nursing staff failed to follow professional standards of nursing practice when performing controlled medication counts. This practice was noted for one (Resident #84) of two residents reviewed for controlled medication administration and one self-reported incident, MD00212528, reviewed during this recertification/complaint survey.

Inspectors wroteBased on resident and staff interview and medical record review, it was determined the facility failed to have documentation which indicated care plans were reviewed and evaluated. This was evident for 1 (#1) of 1 residents reviewed for edema, and 2 (#10, #5) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, interview, and documentation review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to implement an effective system to ensure that symptomatic staff, visitors and vendors did not enter the facility during a declared health emergency.

Inspectors wroteBased on observation, resident and staff interview, it was determined that facility staff failed to have a call bell within reach for a resident who was dependent on staff for activities of daily living. This was evident for 2 (#10, #66) of 15 residents observed in the initial resident pool.

Inspectors wroteBased on review of resident medical record, review of Minimum Data Set (MDS) assessments and transmission, and interview with facility staff, it was determined that the facility failed to ensure that a required subset of MDS information was encoded within 7 days and transmitted within 14 days of a resident's death. This was evident for 1 (Resident #1) out of 2 residents reviewed during the survey who had died.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#7) of 2 residents reviewed for edema.

Inspectors wroteBased on review of resident records and interview with facility staff, it was determined that the facility failed to develop baseline care plans for residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was evident for 1 (Resident #14) of 1 resident who was a new admission to the facility and 1 (Resident #5) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to develop and implement person centered care plans and failed to follow the care plan. This was evident for 2 (#10, #11) of 5 residents reviewed for unnecessary medications and 1 (#16) of 2 residents reviewed in the closed records sample.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional stands of practice as evidenced by the application of compression stockings to a resident without a physician's order. This was evident for 1 (#7) of 2 residents reviewed for edema.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff 1) failed to ensure the physician review the resident's total program of care, including medications, at each visit, and 2) failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure that residents weree seen by a physician at least one every 30 days for the first 90 days. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that the attending physician documented in the resident's medical record what actions had been taken, if any, based on irregularities identified during the medication regimen review. This was evident for 2 (Residents #2 and #10) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' medication regimen did not include unnecessary medication as evidenced by Resident #13 having an as-needed acetaminophen order that, when combined with a scheduled acetaminophen order, exceeded the physician-ordered limit of 3 grams of acetaminophen per day. This was evident for 1 (Resident #13) of 1 resident reviewed for pain management.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by 1) failing to adequately monitor a resident for behavior, side effects, or adverse consequences related to psychotropic medication, and 2) failing to evaluate a resident for a gradual dose reduction of a psychotropic medication. This was evident for 1 (#10) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that hot entrees being prepared for refrigeration were rapidly cooled from 135 degrees (Fahrenheit) to 70 degrees within 2 hours, and then cooled from 70 degrees to 41 degrees within 4 hours for the prevention of foodborne illness. This was evident for 1 of 2 tours of the kitchen and had the potential to affect all residents eating cooked and cooled foods.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (#5) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that the results of the most recent survey of the facility were available for residents to examine. This deficient practice had the potential to affect all residents and visitors.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to administer medication as ordered by the physician to Resident #123. This was evident for 1 of 29 residents selected for review during the survey process.