Meadow Peak Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Specifically, two residents' physicians orders for lidocaine lacked a dosage and did not match the administration record; and the facility staff were taping narcotic medications back into the medication cards. Resident identifiers: 49 and 84.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not ensure that each resident received and that the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were numerous resident complaints about the food served at the facility, there were resident council concerns about the food served at the facility, and the test tray that surveyors sampled was not palatable.

Inspectors wroteBased on interview and record review, it was determined for 1 out of 33 sampled residents, that the facility failed to ensure each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Specifically, one resident's representative was not notified in advance of the risks and benefits or alternatives before starting or when changes were made for psychotropic medications. Resident identifier: 91.

Inspectors wroteBased on interview and record review, it was determined that, for 1 of 33 sampled residents, that the facility did not ensure that a transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Specifically, the facility did not document what documentation was sent with a resident that was discharged to a hospital after a change in condition. Resident identifier: 80.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 33 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a dependent resident was transferred using a Hoyer lift by only one staff member on two separate occasions. Resident identifier: 30.

Inspectors wroteBased on record review and interview, it was determined that for 1 out of 33 sampled residents, the facility failed to ensure that each resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible and who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible. Specifically, one resident who was incontinent of bowel and bladder did not receive services to restore function to the extent possible. Resident identifier: 47.

Inspectors wroteBased on record review and interview, it was determined that for 1 of 33 sampled residents, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice. Specifically, one resident did not have vital signs, weights, and assessments of their AV (arteriovenous) fistula documented before and after dialysis treatments and communication of the patient's status with the dialysis center was not complete. Resident identifier: 49.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to post the nurse staff posting data in a prominent place readily accessible to residents, staff, and visitors and failed to post the resident census on a daily basis. Specifically, the nurse staff posting did not include the resident census and was not in an area that residents and visitors would readily find.

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 33 sampled residents, a resident received more seizure medication than was prescribed on eight different occasions. Resident identifier: 9.

Inspectors wroteBased on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, two insulin pens were not labeled with an open date and a resident was given an inhaler that was not labeled with a resident identifier or open date. Resident identifiers: 9.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to conduct an annual review of its IPCP (infection prevention and control program) and update their program, as necessary. Specifically, there was no documentation indicating that the Infection Prevention and Control Policy was reviewed annually.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop and implement policies and procedures to ensure all of the following: When COVID-19 vaccine was available to the facility, each staff member was offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident or staff member had already been immunized, and before offering COVID-19 vaccine, all staff members were provided with education regarding the benefits and risks and potential side effects associated with the vaccine. The facility also failed to maintain documentation related to staff COVID-19 vaccination that included at a minimum, the following: Staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; [...]

Inspectors wroteAn abbreviated complaint survey was conducted on July 9, 2025. Based on interview, observation, and record review, it was determined that for 1 of 5 sampled residents, that the facility failed to provide the services consistent with the resident's needs and choices. Specifically, a resident was not offered a shower for 15 days. Resident identifier: 1. An abbreviated complaint survey was conducted on July 9, 2025. Based on interview, observation, and record review, it was determined that for 1 of 5 sampled residents, that the facility failed to provide the services consistent with the resident's needs and choices. Specifically, a resident was not offered a shower for 15 days. Resident identifier: 1. Findings IncludeThe surveyor reviewed Resident 1's medical records, and the following entries were observed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 25 sampled residents, a resident that was dependent on cares was left unattended in the shower, sustained a head laceration that required eight staples and six stitches, and the resident sustained a pelvic fracture. Resident identifier: 118.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regime was free from unnecessary drugs. Specifically, for 1 out of 25 sampled residents, staff were not monitoring a resident's blood pressure as instructed in a physician's order. Resident identifier: 33. Findings Included: Resident 33 was admitted to the facility on [DATE] with diagnoses which included end state heart failure, depression, hypertensive heart and chronic kidney disease, encounter for palliative care, chronic combined systolic and diastolic heart failure, anxiety disorder, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, hyperlipidemia, essential hypertension, and gastro-esophageal reflux disease. Resident 33's medical record was reviewed on 5/23/24. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless the PRN order for psychotropic drugs were limited to 14 days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order. In addition, residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. [...]

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner (NP) or clinical nurse specialist. Specifically, for 1 out of 25 sampled residents, a resident had additional labs completed without a physician's order after the resident had completed their antibiotic therapy. Resident identifier: 44.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 23 sampled residents, residents did not receive preventative interventions and/or adequate supervision to prevent falls and accidents from occurring. Resident identifiers: 2 and 35.

Inspectors wroteBased on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the grill in the food preparation area was dirty, the oil in the deep fryer was cloudy, food items in the walk-in freezer were open to air, food items in the walk-in refrigerator were open to air, food items in the dry storage area were open to air, and a dented can was not removed from the area where usable canned goods were stored.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the interdisciplinary team had determined that the right to self-administer medications was clinically appropriate. Specifically, for 1 out of 23 sampled residents, a resident was self administering a medication without an evaluation to determine if the practice was safe. Resident identifier: 6.

Inspectors wroteBased on interview and record review it was determined, the facility did not consult with the resident's physician and notify, when there was a need to alter the resident's treatment. Specifically, for 1 out of 23 sampled residents, a resident's physician was not notified when the resident had a decline in mental status after a fall. Resident identifier: 55.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 23 sampled residents, a nasojejunal (NJ) tube feeding did not have the bag labeled with the formula type, rate of infusion, or the nurse initials who initiated and prepared the infusion. Resident identifier: 27.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that residents unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain grooming and personal and oral hygiene. Specifically, for 1 out of 23 sampled residents, a resident who was dependent on staff for grooming and personal hygiene did not receive the services needed for his toenails. Resident identifier: 47.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice. Specifically, for 1 out of 23 sampled residents, a resident was not provided treatment and care after a fall and the resident had a decline in mental status. Resident identifier: 55.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 23 sampled residents, a resident was receiving an anxiolytic, Diazepam, and had not had a GDR attempted or had an evaluation with rationale by the provider to determine that a GDR was clinically contraindicated. Resident identifier: 6.