Highland Meadows

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for 4 of 6 residents (Residents #46, #55, #70, and #96) reviewed for accident hazards. The facility failed to ensure Residents #46 and #55 did not have a can disinfectant stored in their room. The facility failed to ensure Resident #70 had her fall mat placed alongside her bed for fall prevention. The facility failed to ensure Resident #96 had physician orders for a scoop mattress (a scoop mattress features raised sides and a concave center) to ensure it was not a hazard for the resident. These failures could prevent the residents from having an environment that was free from accidents, and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of seven (Residents #46, #70, and #71) reviewed for respiratory care. The facility failed to ensure Resident #46's nebulizer mask was bagged when not in use on 05/12/26. The facility failed to ensure Resident #70's nasal canula was properly stored in a bag when not in use on 05/12/26. The facility failed to ensure Resident #71's nebulizer and CPAP mask were bagged when not in use on 05/12/26. The facility failed to ensure Resident #71 had physician orders for use of the nebulizer. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for three of seven residents (Residents #29, #46, and #96) reviewed for medication storage. The facility failed to ensure Resident #29 did not have a container of eye drops on his bedside table on 05/12/26. The facility failed to ensure Resident #46 did not have a container of allergy medication and antacid medication on his nightstand on 05/12/26. The facility failed to ensure Resident #96 did not have a container of earwax removal on his nightstand on 05/12/26. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to properly seal the tea dispenser once the tea had brewed on 05/12/26. The facility failed to ensure the ice scoop, in the kitchen, was thoroughly cleaned on 05/12/26. The facility failed to ensure the sanitizer bucket (red bucket) in the kitchen area had the appropriate level of sanitizer fluid in it on 05/12/26. The facility failed to ensure a large tray of thawing raw meat, in the walk-in refrigerator, was not stored above cooked foods. These failures placed residents at risk of exposure to food contamination and illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 12 residents (Resident #46 ) reviewed for care plan. The facility failed to ensure Resident #46's care plan for fall prevention included the intervention of a fall mat placed alongside bed. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #144) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #144. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident #31) of 3 residents reviewed with gastrostomy tubes (g-tubes). CNA A did not inform the nurse to turn off Resident #31's gastrostomy tube feeding prior to providing care. CNA A lowered the head of Resident #31's bed to a flat position for incontinent care while the g-tube feeding continued to infuse. This failure could place residents with g- tubes at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 1 of 6 residents reviewed for unnecessary medications, in that (Residents #70). Resident #70 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #31 and #49) of 6 residents reviewed for infection control in that: 1. CNA A failed to complete hand hygiene during incontinent care while assisting Resident #31. 2. CNA C failed to complete hand hygiene and change gloves during incontinent care while assisting Resident #49. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's attending physician when an injury of unknown origin was discovered on Resident #1. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 1 resident (Resident #1) reviewed for reporting. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their policy regarding storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption of the food and beverages for 9 Residents (#7, #54, #264, #92, #33, #21, #55, #10, and #28) out of 9 reviewed for personal food storage. The facility did not have documentation of temperature checks for the resident's personal refrigerators. The facility staff did not label, date, and clean the nourishment refrigerator for the residents. The deficient practice placed one hundred and ten residents who had used the nourishment refrigerators at risk of food borne illness. The deficient practice placed nine residents who had personal refrigerators at risk of food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of three residents (Resident #21, #95, and #88) reviewed for infection control. 1. MA A touched medications without gloves and administered to Resident #21. 2. MA A failed to clean the blood pressure machine while checking the blood pressure for Resident #21 and #95. 3. CNA B failed to complete hand hygiene while providing incontinent care to Resident #88. These failures could place residents at risk for contamination and infection.