Meadow Park Rehabilitation and Healthcare Center

Inspectors wroteBased on review of complaint #3065681, record review, and interview, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's diagnosis of anemia and the associated risk for complications. This was evident for 1 (Resident #125) of 4 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were treated with dignity and respect when staff publicly labeled residents as feeders on a dry erase board visible from the hallway and nurse's station. This practice compromised resident dignity, confidentiality, and privacy rights and affected Resident (R) #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 and was observed during the complaint survey.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an allegation of verbal abuse was reported and handled in accordance with Centers for Medicare and Medicaid Services (CMS) requirements for 1 (Resident #12) of 1 resident reviewed for abuse allegations during the complaint survey.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the clinical record was accurate, complete, and consistent for 1 (Resident #17) of 1 resident reviewed for an unexpected change in condition during the complaint survey.

Inspectors wroteBased on observations, interviews, clinical record review, and review of facility policy, the facility failed to maintain an infection control program that would prevent and protect residents from the risk of infection for two (2) (Resident #14 and Resident #15) of 35 sampled residents reviewed during the complaint survey.

Inspectors wroteBased on staff interview it was determined the facility failed to provide residents with access to their funds 24 hours a day/7 days a week. This was found to be evident for 1 of 1 residents that were reviewed for care during an annual survey.

Inspectors wroteBased on interviews, observation and record review, it was determined that the facility failed to ensure the residents' personal property was kept from loss. This was evident for 1 (Resident # 65) of 57 residents reviewed during the annual re-certification survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of abuse (Resident #120). This was evident for 1 out of 57 residents reviewed during a complaint/annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASRR) II for a resident. This was found to be evident for 1 (#97) out of 3 residents reviewed for PASRR II completion during the recertification survey.

Inspectors wroteBased on record review, interviews and observations, it was determined that the facility staff failed to adequately monitor a cognitively impaired resident who had exit seeking behaviors. This was found to be evident for 1 (#217) out of 2 residents reviewed for exit seeking behaviors during the recertification survey. This deficient practice was determined to be an Immediate Jeopardy past non-compliance after the investigation was completed.

Inspectors wroteBased on interviews and medical record reviews, it was determined that the facility failed to implement a process to ensure residents receive written notice of room changes. This was evident for 1 (Residents #51) out of 1 resident, who expressed concern regarding room change notification during the recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to report a resident eloped from the facility within the 2-hour allotted timeframe. This deficient practice was evidenced in 1 (#271) of 1 facility reported incident reviewed for an elopement during the recertification survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to ensure a resident's medical record was accurate. This deficient practice was evident for 1 (#217) in 2 medical records reviewed for accuracy during the recertification survey.

Inspectors wroteBased on observations; the review of medical records, administrative reports, and other pertinent documentation; and interviews with facility staff, it was determined the facility failed to prevent Resident #33 from exiting the building unattended on 6/7/22; failed to develop and implement timely interventions to address Resident #93's exit-seeking behavior, and failed to ensure the facility's exterior doors were secured, alarmed, and functioning properly. The deficient practice was evident for 2 of 4 residents reviewed for elopement during the survey; however, the facility's failures had the potential to impact 4 of 4 residents identified as at risk for wandering or elopement. Additionally, the facility failed to ensure that all medication carts remained locked and secured this was evident one medication cart. [...]

Inspectors wroteBased on observations and interviews it was determined the facility staff failed to maintain infection control practices as evidenced by staff not maintaining a resident's oxygen tubing and disposing of waste according to professional standards. This was evident in 1 of the 3 residents observed for infection control practices (Resident #60).

Inspectors wroteBased on observation and interview, the facility failed to maintain the dignity of residents by leaving Resident #45's face soiled with food after the resident was assisted with a meal and neglecting to cover a residents urinary collection bag. This was evident for 2 of 22 residents reviewed during the facility's annual survey (Residents #49 and #159). 1.) The facility staff failed to treat a resident with respect and dignity by failing to cleanse Resident #49's face after feeding him/her breakfast. During observations rounds on 6/7/22 at 9:45 am AM Resident #45 was observed with eggs on the right side of his/her face. A review of Resident #45's medical record on 6/7/22 at 10:00 AM, revealed the resident is totally dependent on staff for care. [...]

Inspectors wroteBased on observation and interview, the facility failed to accommodate the needs of a resident by failing to ensure a resident's call bell was in reach when needed (Residents #9 and Resident #51). This was evident in 2 of 22 residents reviewed during the facility's annual survey.

Inspectors wroteBased on observations and interviews it was determined the facility failed to provide a homelike environment as evidenced by residents having stained linen and soiled equipment in residents' rooms. This was evident for 1 of 4 residents assessed for a clean and comfortable homelike environment (Residents #29).

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to complete an investigation into allegations of abuse. This was found to be evident for 4 of 11 complaints reviewed during the facility's annual Medicare/Medicaid survey (Residents # 366, 367, 368, and # 370).

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to complete a Notice of Transfer when a resident was sent to the hospital. This was evident in 1 of 1 (Resident #37) resident records reviewed for transfer documentation.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure comprehensive Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 of 4 (#23) residents reviewed for dialysis during the revisit survey.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to ensure that a resident's care plan intervention was implemented for making sure the call bell was within reach when needed. This was evident for 1 of 3 (#9) residents reviewed for access to the call bell during the revisit survey.

Inspectors wroteThe facility's staff failed to provide the necessary services to maintain personal hygiene for 2 of 12 residents reviewed during this annual survey (Resident #49 and #79).

Inspectors wroteBased on record review, observations and interview, the facility staff failed to follow a physician's orders by not consistently weighing , and for failing to follow physician orders for the administration of oxygen therapy. This was evident for 2 out of 22 residents reviewed during an annual survey (Residents #61 and #66).

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure a supplement was administered to a resident as ordered. This was found to be evident for 1 out 8 of residents (Resident #49) reviewed during medication order reconciliation.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to ensure that pharmacist recommendations were acted upon and documented in the resident's medical record. This was evident for 2 of 3 (#13, #15) residents reviewed for drug regimen review.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to properly label and store residents' medications in accordance with currently accepted professional principles. This was observed in 2 of the 2 medication storage rooms within the facility.

Inspectors wroteThe facility failed to provide laboratory services to residents (Resident #79). This was evident for 1 of 1 resident investigated for laboratory services in the facility's annual survey.

Inspectors wroteThe facility failed to maintain updated and accurate records including there facility matrix, a record of medical orders for treatment (Resident #75), and emergency contact information for residents (#356). This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1a) assess the resident's Functional Status; b) Bowel and Bladder status; c) Medication Usage for antipsychotic gradual dose reduction and 2) Medication usage for antibiotic use. This was found to be evident for 2 out of 32 residents (Resident #28 and #57) reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to consistently ensure an interdisciplinary team, which included the resident, unit nurse manager, a geriatric nursing assistant and the physician or nurse practitioner contributed to the resident's care plan and failed to ensure care plans were updated and revised as needed as evidenced by failure to update care plans in relation to: 1) the use of a urinary catheter; 2) development of a pressure ulcer and the need for intravenous hydration. This was found to be evident for 2 out of 32 residents (Resident #28, #90) reviewed for care planning during the investigative stage of the survey.

Inspectors wroteBased on medical record review, interview and observation it was determined that the facility failed to provide care in accordance with professional standards of practice as evidenced by the failure to: 1a) ensure nursing assessments were completed as ordered by physician; 1b) provide physician ordered flushes of a intravenous line to maintain patency 1c) complete dressing changes as ordered to an intravenous line; 1d) address possible swallowing issues; 2a) to ensure an antibiotic to treat a wound infection was administered as needed; 2b) to ensure dressing changes for a chronic non-pressure wound were completed as needed; 2c) to ensure blood sugars were monitored as ordered; and 2d) to administer insulin as ordered; 3) to administer pain medication available in the interim box; [...]

Inspectors wroteBased on clinical records review and interview with the facility staff, the facility failed to ensure when a resident was verbalizing feelings of depression the facility clarified which behavioral health recommendations to follow when two treating behavioral health physicians wrote conflicting orders for the resident. This was true for 1 out of 1 resident (Resident #28) reviewed in the investigation portion of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to identify that the wrong dosage of medication was being discontinued which caused the resident to receive a lower dose of a medication that was being used to treat continued depression. This was evident for 1 out of 7 residents (Resident #28) reviewed for unnecessary medication review.

Inspectors wroteBased on review of resident council meeting minutes and interview with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was found to be evident during a resident council meeting, and a review of the resident council meeting minutes that was completed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review, medical record review and interviews with facility staff it was determined the facility failed to notify the resident representative of a treatment change for a resident with a pressure ulcer. This was found to be evident for 1 of 7 complaints (Resident #164) reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews with facility staff and residents, it was determined the facility failed to ensure that residents can submit grievances without fear of reprisal. This was found to be evident for 1 of 6 residents (Resident #101) that attended the resident council meeting conducted during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information. This was found to be evident for 2 out of 3 residents reviewed for hospitalization (Resident #30 and #164).

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the development of a baseline care plan that included instructions needed to provide effective and person centered care within 48 hours of admission. This was found to be evident for 1 out of the 32 residents (Resident #172) reviewed during the investigative portion of the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility to ensure comprehensive care plans were developed for residents as evidenced by failure to address: 1) a non-pressure chronic ulcer; and 2) the use of an indwelling Foley urinary catheter 3) revision of a care plan after treatment discontinuation. This was found to be evident for 3 out of 32 residents (Resident #171, #266 and #83) reviewed during the investigative portion of the survey.

Inspectors wroteBased on observations, medical record review and interviews with facility staff it was determined the facility failed to provide individualized activities for residents and failed to assist resident's to group activities. This was found to be evident for 3 out of 3 residents (Resident #315, #4 and #71) reviewed for activities during the facility's annual Medicare/ Medicaid survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure safety precautions were communicated to staff providing care for a resident. This was found to be evident for 1 out of 6 residents (Resident #172) reviewed for accidents during the survey.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure supplements were administered to residents as ordered. This was found to be evident for 3 out of 32 residents (Resident #71, #30 and #165).

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure pain medication was administered in a timely manner. This was found to be evident for 1 out of 4 residents (Resident #167) reviewed for pain management.

Inspectors wroteBased on interviews with residents, review of resident council meeting minutes and interviews with facility staff it was determined the facility failed to have adequate staff to ensure that response to call lights were timely and that staff provided care assistance requested by the resident in a timely manner. This was found to be evident for 6 out of 6 resident council members (Resident # 18, #63, #72, #74, #101 and #110) interviewed during the survey.

Inspectors wroteBased on review of medical records and employee files and interviews it was determined that the facility failed to ensure skills competency was demonstrated by newly hired nurses and geriatric nursing assistants (GNA) prior to being allowed to work independently with residents. This was found to be evident for 3 out of 3 GNAs (#15, #16, and #17) and 2 out of 2 nurses (#34 and #32) reviewed for new hire skills competency during the survey.

Inspectors wroteBased on review of employee information and interview it was determined that the facility failed to ensure annual evaluations were being completed for nursing staff. This was found to be evident for all nursing and geriatric nursing assistants (GNA) having worked at the facility for more than a year and has the potential to affect all residents.

Inspectors wroteBased on review of medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure pharmacist recommendations resulting from identified irregularities during the monthly pharmacy review were addressed and acted on by the physician as evidenced by failure to address recommendation for gradual dose reduction and failure to identify missed lab test for diabetes monitoring and failure to include required components in the medication regime review policy. This was found to be evident for 2 out of the 5 residents (Resident #28 and #20) sampled for medication regimen review during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility staff failed to adequately monitor the use of antipsychotic medications used to treat a resident's behavior. This was evident for 1 out of 5 residents (Resident #28) reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on medical record review, interview and observation it was determined that the facility failed to ensure medications were secured and accounted for as evidenced by observation of a physician prescribed antibiotic cream being stored in a resident's dresser drawer and nursing staff failure to sign off the administration of a narcotic on the Medication Administration Record (MAR) and the Controlled Substances Record. This was found to be evident during a dressing change observation (Resident #171) and an observation of narcotic count between shifts and has the potential to affect all residents.

Inspectors wroteBased on observations it was determined the facility failed to consistently maintain a sanitary environment in the kitchen based on 2 random observations. This has the potential to affect any resident who consumes food from the kitchen.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to provide services from an outside source to a resident with a pressure ulcer that required ongoing care and treatment. This was found to be evident for 1 of 7 complaints (Resident #164) reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure documentation of specialist assessments were available in the medical record for review by other health care professionals. This was found to be evident for 3 out of the 32 residents (Resident #165, #171 and #20) reviewed during the investigative portion of the survey.