Meadow View Nursing and Rehabilitation

Inspectors wroteBased on observation, facility's CNA job description, record review, and resident and staff interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 1 of 2 residents (Resident #64) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 3 of 23 Residents (#12, #72 and #88) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the resident's wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide the Advance Beneficiary Notice (ABN - CMS-10055 form) for 2 of 3 residents (#19 and #70) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.

Inspectors wroteBased on policy review, record review, review of the Bureau of Facility Standards Long Term Care Reporting System (BFS) portal and staff interview, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 2 hours. This affected 1 of 2 residents (Resident #3) whose records were reviewed for abuse reporting and investigation. This deficient practice created the potential for harm if allegations were not acted upon in a timely manner and the abuse continued.

Inspectors wroteBased on review of state operations manual, observation, and interviews, it was determined the facility failed to ensure residents were provided with a safe homelike environment. This was true for 1 of 3 residents (Resident #64) whose rooms were observed. This deficient practice created the potential for diminished quality of life and water temperature burn risk.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 4 residents (Resident #98) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on record review and staff interview, it was identified the facility failed to ensure residents were properly monitored for pain management. This was true for 2 of 4 residents (#8 and #72) whose records were reviewed for pain management. This failure had the potential to create harm when residents were not monitored adequately for pain.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, observation, and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was accurately posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels.

Inspectors wroteBased on Policy review, observation, record review, and staff interview, it was determined the facility failed to ensure narcotic counts were consistently verified by the off going and on coming nurses. This was true for 3 of 3 medication carts. This failure created the potential for undetected misuse and/or diversion of controlled medications and the potential for harm if a controlled medication was not available when needed.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This failed practice created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff.

Inspectors wroteBased on observation, interview, and review of the Idaho Food Code, the facility failed to ensure staff wore beard nets in the kitchen and appropriately stored, distributed, and labeled foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, staff interviews, and record review, it was determined the facility failed to ensure clean clothing were stored on a clean surface in the laundry area. This deficient practice created the potential for harm due to the increased risk of cross contamination and had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure a residents safety during a mechanical lift transfer resulting in the resident falling during a mechanical lift transfer and sustaining a spinal fracture and to prevent a cognitively impaired resident with wandering/exit seeking behaviors from gaining access to the parking lot without supervision for two of seven residents (Resident (R) 309 and R95) reviewed for accidents in the sample of 21.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed protect the resident's right to be free from physical abuse by staff for one of five residents (Resident (R) 13) reviewed for abuse out of a total sample of 21 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to investigate an injury of unknown origin and an allegation of sexual abuse for two residents out of five residents (Resident (R) 73 and R63) reviewed for abuse out of a sample of 21. Failure to thoroughly investigate and take appropriate action for allegations had the potential to place other residents at risk of abuse/neglect.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to implement a care plan for a resident with a known history of wandering and exit seeking behaviors for a resident who gained access to the facility parking lot without staff supervision or knowledge for one of three residents (Resident (R) 95) reviewed for elopement. This has the potential to affect all residents who were at risk of wandering and elopement.

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to administer nebulized medication correctly for two of two residents (Resident (R) 48 and R103) reviewed for professional standards of 21 sample residents.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents received information and assistance to exercise their rights to formulate an Advance Directive. This was true for 2 of 6 residents (#7 and #8) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated.

Inspectors wroteBased on resident and staff interview, policy review, record review, and review of grievances, it was determined the facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve grievances. This was true for 1 of 18 residents (Resident #79) reviewed for grievances. This failure created the potential for psychosocial harm if resident grievances were not acted upon.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure fall prevention was implemented as care planned. This was true for 1 of 5 residents (Resident #44) reviewed for falls. This failure had the potential for harm if residents sustained bone fractures or other serious injuries from falls.