Meadow Wind Health Care Center

Inspectors wroteBased on record review, staff and resident interview, and review of facility policy, the facility failed to ensure Resident #44 received treatment and care in accordance with professional standards of practice for treatment of urinary tract infection. Actual harm occurred to Resident #44 on 06/07/26, when the facility failed to notify the nurse practitioner (NP) of abnormal urine analysis and culture results, which were positive for Klebsiella pneumoniae ESBL (extended spectrum beta-lactamase) bacteria greater than 100,000 colony-forming units per milliliter, causing a delay in treatment for a urinary tract infection (UTI). The results were not reported to the NP until 06/16/26 at approximately 9:51 P.M. At approximately 11:00 P.M. [...]

Inspectors wroteBased on medical record, policy review and facility staff interviews, the facility failed to provide, timely, baseline care plans to Residents #2, #73, #75, and #90. The affected four of four residents reviewed for baseline care plan completion. The facility census was 77.

Inspectors wroteBased on medical record review, facility policy review, and resident and staff interviews, the facility failed to revise care plans for new diagnoses or changes in condition for Residents #15, #68, #73, and #90. This affected four (Residents #15, #68, #73, and #90) of four records reviewed for care plan revisions. The facility census was 77.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident account management authorizations were signed and witnessed. This affected three residents (Resident #39, #68 and #70) of five residents reviewed for personal funds. The facility census was 77.

Inspectors wroteBased on record review and interview, the facility failed to provide bed hold notices in writing to the resident or resident representative as required. This affected one resident (Resident #70) out of five residents reviewed for discharges. The facility census was 77.

Inspectors wroteBased on record review and interview, the facility failed to ensure the accuracy of resident assessments. This affected two residents (Resident #9 and Resident #11) reviewed for accuracy of assessments. The facility census was 77.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to ensure PASARRs were updated following a significant change in condition. This affected two residents (#6 and #10) out of four residents reviewed for PASARR screening. The facility census was 77.

Inspectors wroteBased on record review, review of the facility investigation, staff and family interviews and review of facility policy, the facility failed to ensure advance directives were honored for residents. This affected one (Resident #91) of two residents reviewed for Cardio-pulmonary Resuscitation (CPR). The facility also failed to ensure advanced directives were accurate in the medical records. This affected one (Resident #28) of 29 residents reviewed for advance directives. The facility census was 77.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure vision services were provided to Resident #90. The affected one (Resident #90) of one resident reviewed for vision services. The facility census was 77.

Inspectors wroteBased on record review, interview and review of facility policy the facility failed to inform the nurse practitioner of a dietary recommendation to address hydration needs for Resident #96. This affected one resident (Resident #96) of four residents reviewed for change of condition. The facility census was 77.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected three (Residents #35, #67 and #70) of four residents reviewed for respiratory care. The facility census was 77.

Inspectors wroteBased on record review, interview and review of the facility assessment, the facility did not ensure licensed nursing staff completed competencies on hire and demonstrated competencies and skill sets necessary to provide care and services based on residents assessed needs. This affected two (Resident #44 and #96) of two residents reviewed for competent nursing services. The facility census was 77.

Inspectors wroteBased on record review, staff and resident interview, and review of facility policy, the facility failed to promptly notify the ordering nurse practitioner of laboratory results that fell outside of normal clinical reference range for Resident #44. This affected one (Resident #44) of two residents (Resident #44 and Resident #96) reviewed for hospitalization. The facility census was 77.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure staff followed proper infection control procedures during incontinence care for Resident #55. The affected one resident (#55) of three residents reviewed for incontinence care. The facility census was 77.

Inspectors wroteBased on observations, policy review, medical record review and interview, the facility failed to implement isolation protocols and failed to maintain infection control during tracheostomy care and blood glucose monitoring. This had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to cover an indwelling urinary catheter drainage bag. This affected one resident (Resident #276) out of two residents reviewed for indwelling urinary catheters. The facility census was 75. Findings Include: Review of the medical record for Resident #276 revealed an admission date 10/03/24 with diagnoses including history of falls, history of urinary tract infection (UTI), chronic kidney disease, and type two diabetes mellitus. Resident #276 required assistance from staff for activities of daily living (ADL) tasks, used a front wheeled walker for ambulation assistance, and was receiving physical and occupational therapy services. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure enteral tube feeding bottles and water flush bags were properly labeled with the flow rate and the date and time the bottles/bags were hung for administration for Resident #176, and failed to ensure orders were obtained for Resident #177 regarding cleaning and flushing of an enteral feeding tube. This affected two residents (Resident #176 and #177) out of two residents reviewed for enteral tube feedings. The facility census was 75. Findings Include: 1. Review of the medical record for Resident #176 revealed an admission date 05/10/24 with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), depression, anxiety, heart failure, and placement of a percutaneous endoscopic gastrostomy (PEG) tube. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure parameters were in place for the administration of pain medications. This affected one resident (Resident #2) of five reviewed for unnecessary medications. The facility census was 75.

Inspectors wroteBased on record review and interview, the facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report. This had the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to accurately assess, document, and treat a new onset of a diabetic ulcer for Resident #80, who was dependent on staff for care. This affected one resident (#80) out of three residents reviewed for skin impairment. The facility census was 79.

Inspectors wroteBased on record reviews and interviews, the facility failed to implement nutritional interventions to monitor Resident #101's weights and thoroughly address weight loss timely. This affected one resident (Resident #101) of three residents reviewed. The census was 81.

Inspectors wroteBased on observation and interview the facility failed to maintain the outside courtyard area (designated smoking area) in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 70.

Inspectors wroteBased on record review and staff interview the facility failed to ensure authorization from a resident or a sponsor with a power of attorney for management of personal funds was attested to by a witness not connected to the facility. This affected one (Residents #22) of five (Resident's #11, #21, #22, #36 and #40) whose personal fund accounts were reviewed. The facility census was 70.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the Ombudsman's office was notified of resident transfers to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70.

Inspectors wroteBased on record review and staff interview the facility failed to ensure bed hold notices were provided to residents upon transfer to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure care conferences were completed as required. This finding affected two (Resident's #10 and #37) of three residents reviewed for care planning. The facility census was 70.

Inspectors wroteBased on observation and interview, the facility failed to ensure the posted nurse staffing information was available daily as required. This finding had the potential to affect all 70 residents residing in the facility.