Meadow Green Nursing and Rehabilitation Center

Inspectors wroteBased on observations and interviews, the facility failed to ensure Resident protected health information (PHI) was secure and not visible to others on two of three nursing units.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for six Residents (#61, #15, #71, #74, #51, #105) out of a total sample of 30 residents. Specifically:For Resident #61 the facility failed to float both heels at all times as indicated in the Resident's plan of care. For Resident #15 the facility a). failed to place floor mats on each side of the bed and b). failed to obtain weights as ordered. For Resident #71 the facility failed to develop an activities of daily living (ADLs) care plan. For Resident #74 the facility failed to develop a comprehensive person-centered care plan for a pacemaker. For Resident #51 the facility failed to develop a comprehensive person-centered care plan for a pacemaker. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for three Residents (#9, #51 and #71) out of a total sample of 30 residents. Specifically:1. For Residents #9, who has a history of difficulty swallowing, the facility failed to provide supervision during meals.2. For Resident #51 the facility failed to provide supervision with meals as indicated in the plan of care.3. for Resident #71 the facility failed to provide supervision with meals as indicated in speech therapy notes.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#71, #66, and #1) out of sample of 30 residents. Specifically, For Resident #71 the facility failed to obtain orders for suctioning and failed to store suction equipment consistent with professional and infection control standards of practice. For Resident #66 the facility failed to maintain a clean filter on the oxygen concentrator. For Resident #1, the facility failed to provide oxygen as indicated in physician's orders, obtain a physician's order for CPAP (Continuous Positive Airway Pressure), and label and date the CPAP supplies.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#85) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of one applicable Resident. Specifically, the facility failed toObtain orders to monitor and assess the Resident's dialysis access site; and Maintain communication with the dialysis center.

Inspectors wroteBased on observation, record review and interview, 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. Specifically, for three Residents (#22, #35 and #71) out of 30 sampled residents, the facility failed to implement Enhanced Barrier Precautions (EBP) as indicated. Specifically,For Resident #22, who has a PICC (Peripherally Inserted Central Catheter) line, the facility did not implement EBP.For Resident #35 who has wounds, the facility did not implement EBP.For Resident #71 who has a gastrostomy tube (a surgically placed tube that delivers nutrition, fluids, or medication directly into the stomach for individuals who cannot eat enough by mouth), the facility did not implement EBP.

Inspectors wroteBased on record review, policy review and interview, the facility failed to provide education regarding vaccine refusals, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four out of five resident records reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure two Residents (#2 and #65) out of 30 sampled residents were free from unnecessary psychotropic medications by ensuring a stop date on a PRN (as needed) psychotropic medication. Specifically, for Resident #2 and Resident #65 the facility failed to ensure that as needed orders for Trazodone (an antidepressant medication) had a stop date.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#71) out of a total sample of 30 residents, after each assessment, including the quarterly review assessment. Specifically, the facility failed to review and revise the care plan after a quarterly assessment was completed to reflect the current status of the Resident.

Inspectors wroteBased on observations, interviews, and record review, the facility to ensure that services provided met professional standards of practice for three Residents (#15, #61 and #71) out of a total sample of 30 Residents. Specifically,For Resident #15 the facility failed to ensure that monthly weights were obtained as indicated in physician's orders. For Resident #61 the facility failed to ensure that monthly weights were obtained as indicated in physician's orders. For Resident #71 the facility failed to ensure that weekly skin checks were completed as indicated in physician's orders.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#72) with a history of pressure ulcers, and assessed as being at high-risk for the development of pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 30 Residents. Specifically, the facility failed ensure the air mattress turned on while the Resident was in bed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during the Monthly Medication Review (MMR) were addressed for two Residents (#2 and #65) out of a total sample of 30 residents. Specifically, the facility failed to review and implement recommendations from the Consultant Pharmacist in regard to a stop date for as needed (PRN) psychotropic medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that medications were accurately reconciled by nursing for one Resident (#104), out of a total sample of 30 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to ensure Cefadroxil (an antibiotic medication) was accurately transcribed in the medical record upon admission to the facility, resulting in the Resident not receiving the complete course of antibiotics.

Inspectors wroteBased on record review and interview the facility failed to maintain accurate medical records for two Residents (#15 and #61) out of a total sample of 30 residents. Specifically:For Resident #15 the facility documented that weights were obtained when they were not. For Resident #61 the facility documented that weights were obtained when they were not.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued with the required information for two out of two applicable residents reviewed. Specifically, the facility failed to issue a complete SNF ABN notice, so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare and were aware of the financial responsibility they may have to assume.

Inspectors wroteBased on record review and interview the facility failed to inform each resident of services available in the facility and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF/ABNs) to two out of two applicable records reviewed. During an interview on 2/26/25 at 2:00 P.M., Social Worker #2 said she had never issued an ABN before. She said that it was the business office that issued the ABNs. During an interview on 2/27/25 at 10:54 A.M., the Administrator said the facility is not issuing the ABNs, but they should be.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for four Residents (#27, #21, #13 and #93) out of sample of 25 residents. Specifically, 1. For Resident # 27, the facility failed to include an oxygen physician's order in the medical record and have oxygen set at the right flow rate. 2. For Resident #21, the facility failed to routinely change and date oxygen tubing for one Residents. 3. For Resident #13, the facility failed to properly store the nebulizer tubing and mask. 4. For Resident #94, the facility failed to properly store and label the nebulizer tubing and mask.

Inspectors wroteBased on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment that prevents the development and transmission of communicable diseases and infections when the facility failed to implement Enhanced Barrier Precautions for three Residents (#306, #95, and #40) out of a total sample of 25 residents and staff wore gloves in the hallways and failed to perform hand hygiene following glove removal.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a dignified environment for two Residents (#33 and #27) out of a sample of 25 residents. Specifically, 1. For Resident #33, the facility staff referred to the Resident by their level of assistance. 2. For Resident #27, the facility staff assisted the Resident with a meal while standing and referred to the Resident by their level of assistance.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for two Residents (#11 and #95), out of a total sample of 25 residents were consistently documented in the medical record.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement care plans for three Residents (#56, #46 and #32), out of a total of 25 sampled residents. Specifically: 1. For Resident #56, who has a history of putting non-food items into his/her mouth, the facility failed to implement the Resident's care plan of removing potentially hazardous items from the Resident's tray. 2 a. For Resident #46, the facility failed to implement supervision during meals as part of his/her Activities of Daily Living care plan. 2 b. For Resident #32, the facility failed to implement supervision during meals as part of his/her nutritional and Activities of Daily Living care plan. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL), last revised 8/23, indicated the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure care and services are provided according to accepted standards of clinical practice for one Resident (#306) out of a total sample of 25 residents. Specifically, for Resident #306, the facility failed to obtain daily weights as indicated in physician's orders.

Inspectors wroteBased on interview and record review the facility failed to ensure that one Resident (#65), out of a total sample of 25 residents, received proper treatment to maintain vision ability. Specifically, the facility failed to refer Resident #65 to a retina specialist for further evaluation as recommended by the optometrist. Findings Include: Review of the facility policy, titled Ancillary Services, updated 8/1/23, indicated, but was not limited to, the following: - Residents will be offered ancillary services including, but not limited to, ophthalmology, audiology, podiatry and psych services. If resident chooses services outside of ancillary services provided at the facility all efforts will be made to ensure they are seen. (sic.) - Schedule of services will be provided with as much information as possible, in a timely fashion as possible. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one Resident (#95) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing out of a total sample of 25 residents. Specifically, the facility failed to ensure recommendations from the consulting wound physician were implemented and that physician's order were in place for an air mattress.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain professional standards in the management and care for urinary catheter devices for one Resident (#306) out of a total sample of 25 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate medical record for one Resident (#21) out of a total sample of 25 residents. Specifically, the nurses documented in the Treatment Administration Record (TAR) that oxygen tubing was replaced when it was not. Findings Include: Review of the facility policy titled charting and Documentation, dated 8/23, indicated the following: Policy Statement -All services provided to the residents, progress toward the care plan goals, and any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, when on 09/28/24 Certified Nurse Aide #1 transferred him/her without assistance from another staff member, and as a result Resident #1 sustained a fractured right ankle, which required surgical intervention to repair.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance from two staff members for transfers, the Facility failed to ensure they developed and implemented a comprehensive care plan that included interventions, goals, and outcomes related to his/her transfer status.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect seven Residents (#5, #100, #19 #108, #26, #62 and #90) from abuse and neglect by staff out of a total sample of 41 residents. Specifically, the facility failed to prevent abuse 1a) after one Resident (#5) alleged that Certified Nursing Assistant (CNA) #16 forced him/her to take a shower and sprayed water in his/her face, causing emotional distress and 2) by neglecting to complete incontinence care for Residents #100, #19, #108, #26, #62 and #90.

Inspectors wroteBased on record review and interview, the facility failed to file and resolve grievances brought to the Resident Council group for four months.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to 1.) ensure that medications were properly labeled after opening in three of three medication carts observed on three of three nursing units. 2.) ensure medication carts were locked when unattended on one of three nursing units.

Inspectors wroteBased on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to 1) ensure education and training was provided to all staff to provide competent, safe, and effective resident care, 2) ensure the grievance procedure was being completed in the facility and 3) ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program. 1. During the survey process, the following was identified: Review of the facility assessment indicated the following competencies need to be completed by staff: -Self-testing competency for staff to perform COVID-19 binax testing weekly and according to DPH guidelines. [...]

Inspectors wroteBased on interview and record review including the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was following the grievance process and completing grievances; 2. ensuring education and competencies were completed per Facility Assessment process/program; 3. ensuring quality of care related to abuse was maintained for two Residents (#5 and #47); 4. ensuring the governance and leadership members sustain a sufficient QAPI program during transitions in leadership and staffing. As a result of the governing body's failure, the facility failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents as well as implement an effective QAPI program.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to: 1) ensure an ongoing, effective QAPI program is implemented and maintained, 2) identify and prioritize problems and opportunities that reflect organizational process, functions, and services provided to residents based on resident and staff input, and other information and 3) ensure the governance and leadership members sustain a QAPI program during transitions in leadership and staffing.

Inspectors wroteBased on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will develop acceptable performance benchmarks and; (d) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

Inspectors wroteBased on observation and policy review, the facility failed to ensure staff followed infection control standards. Specifically,: 1. the facility failed to ensure staff followed droplet precautions while providing care and housekeeping services in rooms with droplet precautions in place on two of three nursing units; and 2. failed to have measures in place to prevent the spread of water borne infections.

Inspectors wroteBased on observations, interviews and policy review the facility 1) failed to provide a dignified existence for three Residents (#26, #7, #39) while dining, 2) failed to provide dignity during care for two Residents (#62 and #45 ) and 3) failed to provide a dignified dining experience in 2 of 3 unit dining rooms. Specifically: 1. For Residents #26, #7 and #39, the residents did not receive the needed assistance at meals and resorted to eating non-finger food items with their hands at meals. 2. For Residents #62 and #45 staff failed to provide privacy during Activity of Daily Living Care. 3. For residents on the [NAME] and Pondview Units the staff failed to ensure dignity while dining.

Inspectors wroteBased on record review, policy review and interview, the facility failed to report allegations of abuse for seven Residents (#5,#26, #62, #90, #100, #19 and #108) within the required two hour time frame out of a total sample of 41 residents.

Inspectors wroteBased on record review and interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required time frame for two Residents (#22 and #51) out of a total sample of 41 residents.

Inspectors wroteBased on observations, record reviews, interviews and policy reviews, the facility failed to follow the plan of care and develop personalized care plans for six Residents (#39, #49, #100, #34, #60 and #71). Specifically, 1. for Resident #39, the facility failed to ensure Fall Eaze mats were in place, as ordered by the physician; 2. For Resident #49, the facility failed to develop a cognitive care plan to address dementia; 3. For Resident #100, the facility failed to a) follow the plan of care to off load the Resident's heel and b) develop a care plan for the diagnosis and behaviors of [NAME] (An eating disorder characterized by a tendency to eat substances that provide no nutritive value such as soil, chalk, hair, paper, etc.); 4. For Resident #34, the facility failed to develop a care plan for the Resident's contracture's; 5. [...]

Inspectors wroteBased on observation, interview and record the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for 16 Residents (#5, #50, #60, #62, #82, #97, #26, #39, #224, #62, #90, #19, #100, #108 #97, #47) out of a total sample of 41 residents. Specifically, 1. for Residents #5, #50, #60, #82, #97, #26, #39 and #224 the facility failed to ensure feeding assistance and supervision with meals was provided. Resident #5's lack of supervision resulted in the Resident having a burn from hot coffee; 2. For Resident #26, #62, #90 #19, #100, #108 #97 and #82, the facility failed to ensure incontinence care was provided as required. 3. For Resident #47, the facility failed to provide assistance with hygiene.

Inspectors wroteBased on in-service documentation review, employee record review and interview, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for four out of four Certified Nursing Assistants (CNAs), and four out of four licensed nurses whose education records were reviewed.

Inspectors wroteBased on employee record review and interview, the facility failed to complete a performance review of Certified Nursing Assistants (CNAs) at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews for 4 out of 4 CNAs employee records reviewed.

Inspectors wroteBased on record review and interview the facility failed to maintain accurate medical records for five Residents (#122 #26, #39, #48, #84) out of a total sample of 41 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure Certified Nurse's Assistants (CNAs) received the required in-service training. Specifically, the facility: 1.) failed to provide no less than 12 hours of training per year; 2.) failed to include dementia management training as required; and 3.) failed to address areas of weakness as determined in CNA's performance reviews, for four out of four CNA employee records reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#97, and #82) out of a sample of 41 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#50) was assessed for the ability to self-administer medications out of a total sample of 41 residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a call light was within reach for one Resident (#7) out of a total sample of 41 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident's Protected Health Information (PHI) was secure and not visible to others on two of three nursing units.

Inspectors wroteBased on record review and interview, the facility 1. failed to make information on how to file a grievance or complaint available to the residents of the facility and 2. failed to file and resolve grievances for three Residents (#47, #100 and #5) out of a total sample of 41 residents.

Inspectors wroteBased on observations, interviews and records reviewed for one resident (Resident #101) of 41 sampled residents, the facility failed to prevent the use of restraints without appropriate assessment.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to implement their abuse policy for one Resident (#5) out of a total sample of 41 residents. Specifically, the facility failed to implement a timely investigation and report within the required two hour time frame to the Department of Public Health's (DPH's) Health Care Facility Reporting System (HCFRS) when Resident #5 reported that a Certified Nursing Assistant (CNA) forced Resident #5, against his/her will, to take a shower and purposefully sprayed water in his/her face during the process. Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; [...]

Inspectors wroteBased on interviews, record review and policy review, the facility failed to investigate allegations of abuse for 2 Residents (#5 and #47) out of a total sample of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of the transfer/discharge notice upon transfer to the hospital for one Resident (#121) out of a total sample of 41 residents.

Inspectors wroteBased on interview, record review and policy review, the facility failed to complete quarterly care plan meetings for two Residents (#48 and #51) out of a total sample of 41 residents.

Inspectors wroteBased on record review, policy review, observation, and interview, the facility failed to ensure staff administered medication in a manner that met professional standards of care for one Resident (#48) out of a total sample of 10 residents. Specifically, staff failed to administer lidocaine patches per the physician's order.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to provide an activities program that met the interest of, and supported the physical, mental, and psychosocial well-being of one Resident (#54) out of a total sample of 41 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#71, and #12) out of a total sample of 41 residents to prevent accidents/incidents. Specifically: 1. For Resident #71 the facility failed to provide supervision to prevent the Resident from placing non edible items into his/her mouth creating a choking risk. 2. For Resident #12 the facility failed to provide supervision while consuming hot coffee.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide dental services for one Resident (#64) out of a total of 41 residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide the correct ordered therapeutic diet to ensure safety while eating for three Residents (#19 #5 and #60) out of a total sample of 41 residents. Specifically, 1) Resident #19 was not provided with pureed vegetables as ordered, 2) Resident #5 was not provided with ground diet as ordered, 3) Resident #60 was provided with foods not adhering to his/her ground diet.

Inspectors wroteBased on record review, document review and interview the facility failed to ensure that hospice services meet professional standards and principles that apply to individuals providing services in the facility, and have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. Specifically: [...]

Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident.

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of the bed-hold notice upon transfer to the hospital for one Resident (#121) out of a total of 41 sampled Residents.