Meadow Lakes

Inspectors wroteBased on interview and record review it was determined that the facility failed to consistently ensure Minimum Data Set (MDS) assessments were submitted within the required time frame. This deficient practice occurred for 8 of 8 system selected residents (Resident #4, #6, #19, #22, #36, #42, #48, and #53) reviewed for timely submission of MDS and was evidenced by the following: On 3/12/25 at 11:01 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RNMDS) regarding the MDS'. The surveyor provided a list of MDS and requested a validation report regarding timeliness. The RNMDS stated she knew she had late MDS submission. On 3/12/25 at 1:24 PM the RNMDS provided the following validation reports: 1. Resident #6; Target Date: 11/3/24: Message: Assessment Completed Late: Z0500B (12/28/24) is more than 14 days after A2300 (Assessment Reference Date). 2. Resident #4; Target Date: [...]

Inspectors wroteBased on interview and document review it was determined that the Facility Assessment (FA) failed to identify and include the staff competencies and skill sets necessary to provide the type of care required for the resident population. This deficient practice had the potential to affect all residents and was evidence by the following: On 3/12/25 at 11:20 AM, the Licensed Nursing Home Administrator (LNHA) provided a copy of the FA dated July 23, 2024 which revealed an attendance sheet with an Agenda that included, but was not limited to; Data- Disease/Conditions/Physical Behaviors needs/ Cognitive disabilities/Acuity and Staff Competencies and Skill Sets. The body of the document included Staff Competencies/Skill Sets, 40% Alzheimer's/Dementia; Resident Count and Acuities: .Short term stays are 100% joint replacement are hips, Pressure ulcers . [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to self-identify all areas for improvement, then develop, implement and maintain a comprehensive, measurable, data driven Quality Assurance and Performance improvement (QAPI) program to address all systems and review significant events at QAPI. The deficient practice had the potential to affect all residents and was evidenced by the following: Refer to F550, F677, F678 On [DATE] at 9:22 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI program. The surveyor asked the LNHA to identify all the current QAPI plans. The LNHA stated that call bell response was identified from the resident council, and from grievances and the LNHA provided the surveyor with the QAPI plan which was reviewed in the presence of the LNHA. The Problem Statement revealed: [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide a dignified dining experience by failing to a) provide incontinence care to a resident prior to providing the lunch meal, and b) appropriately provide dining assistance in a dignified manner, and ensure appropriate resident engagement during the lunch meal. This deficient practice occurred for 4 of 4 residents (Resident #13, #27, #29 and #46) reviewed for dining and was evidenced by the following: 1. On 3/12/25 at 12:06 PM, the surveyor observed Resident #13 in the day room next to a Certified Nursing Aide (CNA) #1 who was preparing to assist the resident with the lunch meal. The surveyor smelled an odor of feces and then observed Resident #13's incontinence brief was bulging. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide adequate supervision for a resident who was identified at risk for falls and sustained multiple falls. This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for falls and was evidenced by the following: On 3/13/25 at 8:31 AM, the surveyor observed Resident #47 in their room and was being assisted by a Certified Nursing Aide (CNA). The resident was non verbal and did not open their eyes upon approach. At the CNA then wheeled Resident #47 in into the dayroom, then shortly after returned the resident to their room and left the resident unattended in their room. On 03/13/25 at 8:45 AM, during an interview with the surveyor the Hospice Aide (HA) stated that she cared for Resident #47 and left the resident alone in their room. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to administer pain medication as ordered by the physician. This deficient practice was identified for 1 of 3 residents reviewed for pain management (Resident # 33) and was evidenced by the following: On 3/12/25 at 9:30 AM, during the initial tour of the facility, Resident #33 reported to the surveyor that they were experiencing constant pain and did not receive their pain medications for a few days. On 3/13/25 at 8:52 AM, the surveyor interviewed the resident in their room. The resident informed the surveyor that there was a lack of communication among staff and no teamwork. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) consistently complete the Dialysis communication form (CF) for the residents on hemodialysis (HD) a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure), and b) monitor, assess and document the care of a hemodialysis access site pre and post HD treatment. This deficient practice was identified for 1 of 1 resident (Resident #15) and was evidenced by the following: On 3/12/25 at 12:56 PM, the surveyor did not observe Resident #15 in their room. The Licensed Nurse Practical (LPN) informed the surveyor that the resident was in the salon. [...]

Inspectors wroteBased on observation, interview, record review and document review, it was determined that the facility failed to a.) follow appropriate infection control protocols during a wound treatment observation. This deficient practice was identified for 1 of 2 residents (Resident # 54) reviewed with wounds, b.) perform hand hygiene (HH) between serving food, removing dirty dishes, and when assisting residents. The deficient practice was identified in 1 of 1 dining room meal observation, for 3 of 4 residents (Resident #27, #29 and #46) reviewed for dining and was evidenced by the following: 1. On 3/14/25 at 10:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to the sacral area of Resident #54, two certified Nursing Aides (CNA) assisted the LPN during the wound treatment. [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide appropriate incontinence care for a resident (Resident #13) who was dependent on staff for Activities of Daily Living (ADL) for 1 of 1 residents reviewed for ADLs. This deficient practice was evidenced by the following: 1. On 3/12/25 at 12:06 PM, the surveyor observed Resident #13 in the day room next to a Certified Nursing Aide (CNA) #1 who was preparing to assist the resident with the lunch meal. The surveyor smelled an odor of feces and observed Resident #13's incontinence brief was bulging. At that time, CNA #1 stated that the resident required total care and had had incontinence care that morning. The surveyor inquired about the resident requiring incontinence care. CNA #1 did not provide incontinence care and assisted Resident #13 with lunch. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to a) consistently ensure physician orders for residents' wishes for life-sustaining treatment were documented in the medical records. This deficient practice was identified for 1 of 1 closed record reviewed for cardio-pulmonary resuscitation (CPR-a medical procedure involving repeated compressions of a person's chest, performed in an attempt to restore blood flow to and breathing of a person whose heart stopped) and was evidenced by the following: A review of Resident #18's closed medical record revealed that Resident #18 was admitted to the facility for short term rehabilitation. Review of the Physician Order Summary (POS) dated February 2025, did not include an order for DNI/DNR (do not resuscitate/do not intubate (to insert a tube into a person's throat, to help with breathing). [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure a resident received their physician ordered medication. This deficient practice was identified for 1 of 5 residents (Resident #48) observed during medication administration. This deficient practice was evidenced by the following: On 3/12/25 at 8:20 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications to administer to Resident #48. The LPN and surveyor observed that the container for the medication Risperdal (an antipsychotic) 2 milligrams (mg) was empty. The LPN stated that medications were to be reordered when there were 10 doses left. A review of the admission Face Sheet revealed that Resident #48 had diagnoses which included, but were not limited to; Bipolar disorder. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist were acted upon in a timely manner and documented for 4 of 5 residents (Residents #11, #14, and #39) reviewed for unnecessary medications. This deficient practice was evidenced by: 1. According to the Face Sheet, Resident #11 had diagnoses that included, but were not limited to: respiratory failure (a condition that makes it difficult to breathe on your own), iron deficiency anemia (a condition in which the blood doesn't have enough healthy red blood cells), and congestive heart failure (a condition in which the heart doesn't pump blood as well as it should). [...]

Inspectors wroteBased on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 01/04/23 between 09:57 AM and 10:42 AM, the initial tour of the kitchen was completed in the presence of the Director of Dining Services (DDS), the surveyor observed the following: 1. [NAME] #1 was observed leaning over to observe the contents inside the tilt skillet. The surveyor observed that [NAME] #1 had a tall white hat on top of his head with exposed hair on the side and back of his head. He was not wearing a hair net. During an interview with the surveyor at that time, [NAME] #1 stated, I thought because I had a hat on I did not need to wear a hair net. [...]

Inspectors wroteBased on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to perform new admission COVID-19 testing per facility policy and in accordance with the Centers for Disease Control and Prevention guidelines (CDC) for infection control to mitigate the spread of COVID-19 for 7 out of 10 residents reviewed that had been admitted in the last 30 days. According to the U.S. CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022 .3. Setting-specific consideration .Nursing Homes Managing admissions and residents who leave the facility: o Testing is recommended at admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 01/04/22 at 10:30 AM, the surveyor observed the emergency water storage area in the presence of the Director of Dining Services (DDS). The resident census on the day of observation was 44. The surveyor observed 2 cases that contained six (6) 1-gallon bottles each, plus an additional one (1) gallon of water for a total of 13 gallons. The DDS stated that they should have 3 gallons of water per resident for 3 days in storage. He further stated it was important to have the water in storage because you never know what mother nature will do. The DDS then confirmed that this was the only water stored for the facility. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Resident #14, 1 of 15 residents reviewed for an evaluation of a significant change in the resident's condition. The deficient practice was evidenced by the following: The surveyor reviewed Resident #14's medical record and noted the following: According to the Face Sheet, Resident #14 was readmitted to the facility with diagnoses that included but were not limited to: displaced fracture of left femur, (a fracture where the pieces of your bone moved so much that a gap formed around the fracture where the bone broke) lack of coordination and fall. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to clarify as needed pain medication orders in accordance with professional standards. This deficient practice was identified for Resident #11, one of 5 residents reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for a floor mat for 1 of 3 residents (Resident #39) reviewed for accidents. The deficient practice was evidenced by the following: During the tour of the B unit on 01/04/23 at 10:20 AM, the surveyor observed Resident #39 sitting on the side of their bed with their legs hanging towards the floor. The surveyor observed that there was no floor mat near the resident's bed or visible anywhere in the resident's room. When interviewed, Resident #39 stated that they had several medical diagnoses and that they had been in the facility's healthcare unit for about 2 years. According to the admission Record, Resident #39 was admitted to the facility with diagnoses that included, but were not limited to: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to evaluate the performance of Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 4 of 5 randomly sampled CNAs whose personnel records were reviewed and was evidenced by the following: On 01/09/23 at 08:47 AM, a review of the personnel records for the selected CNAs that were provided by the facility revealed the following: CNA #1 was hired on 12/12/05. A Performance Enhancement Program for Staff dated 05/03/21. CNA #2 was hired on 09/28/87. A Performance Enhancement Program for Staff dated 12/20/17. CNA #3 was hired on 12/27/17. A Performance Enhancement Program for Staff dated 05/03/21. CNA #4 was hired on 10/08/10. A Performance Enhancement Program for Staff dated 05/03/21. On 01/09/23 at 09:08 AM, the surveyor requested the most recent employee evaluations. [...]