Meadowbrook Acres

Inspectors wroteBased on observation, record review and staff interview the facility failed to develop and implement the care plan for applying bed rails to the beds. This was true for three (3) of the eleven (11) residents that were reviewed for bed rails. Resident Identifiers: #49, #30 and #19. Facility Census: 58 Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers. On 11/04/25 at 10:20 AM review of the care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. Resident #49s interventions./tasks show Bilateral 1/2 side rail to aid in turning and repositioning. On 11/04/25 at 10:45 AM observation of Resident #49 shows she has no side rails in place at this time.

Inspectors wroteBased on record review, staff interview, and observation the facility failed to provide care in accordance with professional standards of practice, by not following doctors orders for side rail implementation and neuro checks. This failed practice was found true for (4) four of (4) four residents reviewed for fall interventions during the Complaint Survey Process. Resident identifiers #19, #30, #49, and #23. Facility Census 58. Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers ordered on 08/14/24. The care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. Resident #49s interventions./tasks show Bilateral 1/2 side rail to aid in turning and repositioning. [...]

Inspectors wroteBased on observation, and staff interview the facility failed to provide residents with a dignified activity experience by passing medications during Bible Study. This failed practice was a random opportunity for discovery during the Complaint Survey. Resident identifier #9. Facility Census 58. Findings Include:a) Resident #9An observation on 11/04/25 at 2:18 PM, revealed the recreation room door to be closed and a sign that read, Bible Study on the closed door. Further observation revealed Registered Nurse (RN) #48, opening the closed door that read, Bible Study and administering Resident #9 a medication. During an interview on 11/04/25 at 2:30, RN #48 stated, If we are running behind we give them during activities or in the dining room. SA asked the RN if he was behind today and RN #48 stated, Not really, I just wanted to get done. [...]

Inspectors wroteBased on record review, and staff interview the facility neglected to provide supervision and monitoring to prevent repeated elopement's. This failed practice resulted in Resident #60 having over 20 attempted elopement's and/or exit seeking behaviors during a (9) nine month period. This failed practice was found true for (1) one of (3) three residents reviewed for elopement risk during the Complaint Survey Process. Resident identifier #60. Facility Census 58. Findings Include:a) Resident #60A review on 11/04/25 at 2:15 PM, revealed a reportable incident for Resident #60 for an elopement dated 04/22/24. The elopement is summarized as follows: On 04/22/24 the facility received a phone call from a (Local Emergency Room) saying that Resident #60 had been brought in by someone and that she had eloped from this nursing home. [...]

Inspectors wroteBased on record review, and staff interview the facility failed to ensure the environment in which it had control over was as free from accidents/ hazards as possible, by not providing supervision and monitoring to prevent repeated elopements. This failed practice was found true for (1) one of (3) three residents reviewed for elopement risk during the Complaint Survey Process. Resident identifier #60. Facility Census 58. Findings Include:a) Resident #60A review on 11/04/25 at 2:15 PM, revealed a reportable incident for Resident #60 for an elopement dated 04/22/24. The elopement is summarized as follows: On 04/22/24 the facility received a phone call from a (Local Emergency Room) saying that Resident #60 had been brought in by someone and that she had eloped from this nursing home. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a resident smoking in non-designated areas, a medication cart and janitor closet unlocked and unattended. Resident identifier: #5. Facility census: 54.

Inspectors wroteBased on observation, record review and staff interview it was determined the facility failed to ensure proper reconciliation of the narcotic medication logbook was performed. Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to store plate lids in accordance with professional standards for food service safety related to storage. This could have affected all residents that received their nutrition from the kitchen. Facility Census:

Inspectors wroteBased on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: # 211. Facility census: 54.

Inspectors wroteBased on record review, and staff interview, facility failed to ensure residents and/or their medical representatives were given the right to be informed of participate in the decision to initiate a psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #4 . Facility census: 54.

Inspectors wroteBased on observation, staff interviews, electronic medical record and policy review the facility failed to ensure they implemented their policy regarding the training of nurse aide staff following a substantiation of allegations of neglect. This is true of one (1) of six (6) residents reviewed for abuse and neglect. Resident identifier: #161. Facility census: 54.

Inspectors wroteBased on record review, and staff interview. The facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for one (1) of one (1) residents reviewed for ADL care. Resident identifier:164. Facility census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) monthly pharmacy reviews were reviewed by the facility physician for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Include: a) Resident #35 On 04/09/25 at 1:03 PM, a record review was completed for Resident #35. The review found two (2) monthly pharmacy reviews, 03/2024 and 01/2025, were not signed by the facility physician. The pharmacy reviews had no indication if the facility physician agreed or disagreed with the pharmacy recommendations. On 04/14/25 at 10:32 AM, the Administrator confirmed neither of the two (2) pharmacy reviews were signed by the facility physician.

Inspectors wroteBased on record review, and staff interview, facility failed to ensure residents was free from unnecessary medications in regard to psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Included: a) Resident #35 On 04/09/25 at 10:00 AM, a record review was completed for Resident #35. The review found two (2) medications without diagnoses. The medication is as follows: --Eye Scrubs External Pad apply to eyes topically every day, which started on 11/07/24. --Metoprolol Tartrate 25mg (milligram) by mouth twice daily, which started on 03/08/25. On 04/09/25 at 4:00 PM, the Administrator and the Director of Nursing (DON) confirmed the medication did not have diagnoses.

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for each resident related to resident's behaviors. This is true for two (2) of two (2) residents reviewed for behavioral care plans. Resident Identifiers: Resident #43 and Resident #6. Facility Census: 59 Findings Include: a)Resident #43 During a review of the reportable dated 04/08/24, Resident #43's incident was as follows: Reported to this nurse per restorative aide that resident was sitting in quiet lounge beside another resident (2935) touching her, when he put his hand in her face and she bit him on the pointer finger. Residents separated, small red bite mark to pointer finger on 2935 has since dissipated. (Physician name) made aware and verbalized understanding. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's drug regimen was reviewed at least once monthly by a licensed pharmacist or failed to ensure when the drug regimen was reviewed, and an irregularity was identified, the resident's physician responded with a rationale for the response made after review. This was true for four (4) of (5) residents reviewed for the unnecessary medication review care area during the Long-Term Survey Process (LTCSP). Resident identifiers: Resident #108, #4, #9 and #27. Census: 55.

Inspectors wroteBased on observation and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open and failed to dispose of expired food items. The facility also failed to keep an accurate refrigerator temperature log. The facility also failed to distribute and serve food and ice in a safe and sanitary manner. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and ice from the B hall Ice chest. Facility Census: 55 Findings Included: a) Walk In Refrigerator During the initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 04/17/23 at 10:30 AM, the following items were found in the walk-in refrigerator: -A pan of Chicken with the tin foil ripped exposing the chicken. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure, residents with physician orders and care plan approaches for Enhanced Barrier Precautions, were implemented, placing all residents at risk for transmission of infections. In addition, the facility failed to ensure residents were provided hand hygiene prior to meals and failed to ensure the proper storage of linens to prevent the spread of infection. This practice had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #31, # 108, #44, #29, #49, #19, and #53. Census: 55.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The steam table drain was leaking around a shut off valve. The steamer was leaking water around the seal when opened. The walk-in freezer had ice build up on the shelving unit, on boxes of frozen food and on the floor. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility kitchen. Facility Census: 55 Findings Included: a) Steam table drain During the initial tour of the kitchen beginning on 04/17/23 at 10:30 AM with the Certified Dietary Manager (CDM) an observation of the steam table drain shut off valve had water dripping into a pan. During an immediate interview the CDM stated, Maintenance has tried to fix it, I think the whole thing needs replaced. [...]

Inspectors wroteBased on observation, resident interview, and record review, the facility failed to ensure all residents were treated with dignity and respect. This was a random opportunity for discovery during the Long Term Care Survey Process, and was only true for Resident #37. Resident identifier #37. Census 55. Findings Included: a) Resident #37 Resident #37 was observed sitting outside of the conference room, in the hallway, with what appeared to be urine soaked pants on. A member of the survey team notified an unidentified staff member who stated she would take the resident to the nurses station and get someone to assist the resident with getting cleaned up. This occurred on 04/17/23 at approximately 2:30 PM. At 2:55 PM the same day, the resident was again observed in her scoot chair sitting at the nurses station. [...]

Inspectors wroteBased on observation, record review, policy review and staff interview the facility failed to ensure each resident was free from physical restraints which are not required to treat the resident's medical symptoms. This was true for one (1) of one (1) residents reviewed for the care area of restraints during the long term care survey process. Resident Identifier: #21 Facility Census:

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the resident and/or the resident's representative, in writing, of the reason for the transfer/discharge to the hospital or to send a copy to the ombudsman for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55. Findings Included: a) Resident #55 A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. The transfer/discharge notice was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23. At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55. Findings Included: a) Resident #55 A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. Evidence of the bed hold policy being sent with the resident was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23. At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. [...]

Inspectors wroteBased on resident interviews, staff interview, and record review, the facility failed to allow residents to be involved in developing their care plan and making decisions about his or her care for two (2) of 24 residents reviewed for the category of care planning, during the long term care survey. Resident identifiers #45 and #7. Census 55. Findings Included: a) Resident #7 An interview with Resident #7 on 04/17/23 at 11:32 AM, resulted in the resident stating he has never heard of a care plan meeting nor has he ever been invited to his care plan meeting. On 04/18/23 at 10:56 AM, a staff interview was conducted with social worker (SW) #56. SW #56 stated resident #7 has been invited to his care plan meetings in the past but it's probably been a long time since he has been invited. This is because he usually cusses the staff and wants his wife to do everything. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to follow physician orders for heel protectors. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long term care survey process. Resident Identifier: #2 Facility Census: 55 Findings Included: a) Resident #2 On 04/18/23 at 9:10 AM, 12:40 PM and 3:58 PM Resident #2 was observed with no heel protectors on. Record review found an order dated 03/02/23 which reads Resident to have bilateral heel protectors in place (may remove for personal hygiene) every shift for skin breakdown prevention. At 3:58 pm on 04/18/23 the Director of Nursing (DON) confirmed Resident #2's heel protectors were not on as ordered by the physician. .

Inspectors wroteBased on Medical record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A quarterly smoking assessment was not completed for Resident #9 who is the facility's only smoker. This was true for one (1) of one (1) residents reviewed for the care area of smoking during the long term care survey process. Resident Identifiers: # 9. Facility census: 55. Findings Included: a) Policy Review Record review of the facility's policy titled, Resident Smoking, showed: -All Residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and record review, the facility failed to provide hydration care and services for one (1) of 24 residents reviewed for hydration, during the long term care survey. Resident identifier #7. Census 55. Findings Included: a) Resident #7 Observation on 04/17/23 at 11:32 AM, found the resident did not have a water pitcher or cup at bedside. A resident interview on 04/17/23 at 11:32 AM, confirmed he did not have anything to drink. He stated, I normally has a pitcher of water. Staff interview on 04/17/23 at 11:40 AM, with Licensed Practicing Nurse (LPN) #24, confirmed the resident did not have any water at bedside. LPN #24 said the resident recently changed to thickened liquids and the staff must have taken his cup away with his breakfast tray. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to follow their policy to store the nebulizer mask in a sanitary manner. This was true for one (1) of one (1) resident reviewed for the oxygen care area during the long term care survey process. Resident Identifier: #44 Facility Census: 55 Findings Included: a) Resident #44 An observation on 04/17/23 at 11:35 AM, found Resident #44's nebulizer mask was on the bedside table and not stored in a sanitary manner. This was confirmed with Licensed Practical Nurse #16 on 04/17/23 at 11:40 AM. The Oxygen Administration Policy (not dated) states under the Policy Explanation and Compliance Guidelines: #5 Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: [...]

Inspectors wroteBased on record review and staff interview the facility failed to evaluate residents for an acceptable diagnosis for the use of psychotropic medications. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: #9 and #36. Facility census: 55.

Inspectors wroteBased on observation, recipe review and staff interview the facility failed to provide food prepared by methods that conserve the nutritive value and the appearance of the food. This practice had the potential to affect an isolated number of residents who receive their nutrition from the kitchen. Facility census 55. Findings Included: a) Brussels Sprouts During a tour of the kitchen on 04/17/23 at 11:45 AM, while obtaining the temperatures on the steam table there was a roundish, shriveled up vegetable which was brown in color. This surveyor asked Is that mushrooms, to clarify what the vegetable was. The Certified Dietary Manager (CDM) stated, no that is our substitute vegetable, Brussels sprouts. This surveyor then stated, but they are brown not green. The CDM stated She [NAME] them in the oven, that is probably why. [...]

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to provide a spouted cup for Resident #25 at meal time. This was a random opportunity for discovery during the observation of the noon time meal on 04/17/23. Resident Identifier: Resident # 25. Facility Census: 55 Findings Included: a) Resident #25 During a dining observation on 04/17/23 at 12:35 PM. Resident #25's lunch meal tray ticket was reviewed. This review revealed the following: .Texture: Regular 4 Adaptive Equipment: Spouted Cup. Resident #25 had his meal tray in front of him and there was no spouted cup on the tray. During an interview on 04/18/23 at 12:36 PM Nurse Aide (NA) #1 acknowledged the spouted cup was not on the lunch meal tray and should have been. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by not having a witness to the consent. Resident identifiers: #19. Facility census: 55.

Inspectors wroteBased on observation and staff interview the facility failed to ensure waste was properly contained and covered in the outside garbage receptacle. The lids of the dumpster's were left open, exposing bags of garbage and boxes. This deficient practice had a potential to affect more than an isolated number of residents residing in the nursing facility. Facility Census: 55. Findings Included: a) Garbage Receptacles During an observation on 04/17/23 at 11:52 AM, there were two (2) outside garbage receptacles, the lids to the dumpster's were open exposing bags of garbage and boxes. During an interview on 04/17/23 at 11:54 AM, the Certified Dietary Manager acknowledged the dumpster lids need to be closed. During an interview on 04/17/23 at 1:43 PM, the Maintenance helper #73 stated the lids on the trash blow up all the time because they don't break down the boxes. [...]

Inspectors wroteBased on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 54 Findings Included: During an interview on 03/14/22 on 12:50 PM, the Dietary supervisor (DS) #1, which was hired on 03/15/21, stated he was not a Certified Dietary Manager (CDM). He indicated he took the CDM class in 2015 and was supposed to test the day COVID hit. He further confirmed he has not rescheduled to take the test yet. During an interview on 03/15/22 at 9:32 AM DS #1 was asked how often the Registered Dietician visits the facility. DS #1 replied the RD #21 visits on Wednesday and Fridays. During an interview on 03/15/22 at 12:05 PM the Administrator stated the RD works 16-20 hours a week. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to employee an Infection Preventionist (IP)who met all required qualifications. This failed practice has the potential to affect all residents currently residing in the facility. Findings Included: During record review it was determined the IP, RN #6 did not have the required certification on file. During an interview with RN #6 on 03/16/22 at 02:59 PM she states she has been in the IP position since 02/18/22 but is not yet been certified. She registered on 03/15/22 for the class and will be fulfilling the qualifications soon. .

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for seven (7) of seven (7) residents reviewed during the Long Term Care Survey Process. Resident Identifiers: Resident # 39, #35, #2, #54, #17, #25 and #45. Facility Census: 54. Findings Included: a) #39 On 03/14/22 at 4:20 PM the POST form for Resident #39 was reviewed. The POST form was signed and dated by the physician on 08/05/21. The POST form was missing the physician's printed full name and telephone number which were left blank. During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to report falls with serious bodily injury to state and other appropriate agencies as required within two (2) hours of discovering the serious bodily injury. This was true for four (4) of four (4) records reviewed during the Long Term Care Survey. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54 a) Resident # 46 According to a record review, Resident #46 had two (2) unwitnessed falls on 07/27/21. The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling to the right knee and a new order for an X-ray of the right knee was obtained. On 03/16/22 at 02:20 PM this was confirmed with LPN #71. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to thoroughly investigate falls with serious bodily injury as required. This was true for four (4) of four (4) records reviewed. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54 a) Resident # 46 According to record review, Resident #46 had two (2) unwitnessed falls on 07/27/21. The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling of the right knee and a new order for an X-ray of the right knee was obtained. On 08/03/21 when the Physician assessed the Resident and upon observing the right knee being swollen, the Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide care and services according to professional standards of care and the resident's plan of care. This is true for five (5) of 25 residents reviewed during the long term care survey process. Resident Identifiers #54, #205, #46, #44, and #35. Facility census 54. Findings Included: a) Resident #54 An observation of the medication pass on the A hallway at 9:20 am on 03/16/2022 found Licensed Practical Nurse (LPN ) # 56 administered a Symbicort (a steroid inhaler) to Resident #54. After administration of the steroid inhaler Resident #54 was not asked to rinse her mouth. Review of the facility policy Medication Administration failed to advise to have the resident to rinse their mouth after administering a steroid inhaler. According to the Symbicort manufacturers guideline: After using your SYMBICORT inhaler: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to complete an accurate and complete record of controlled substances in the narcotic count book. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 54. a) Narcotic Count Book The Controlled Substance Administration and Accountability Policy was reviewed and states in section 3 (three) ordering and receiving controlled substances in subsection e, The medications delivered are immediately recorded on the appropriate drug disposition record . On 03/16/22 at 9:12 AM, Licensed Practical Nurse (LPN) #71 confirmed the index of the Narcotic Count Book was blank. The Index did not list the name of the residents, medications, dosages and page number for each controlled substance. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document dishwasher temperatures. This deficient practice has the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census: 54 Findings Included: a) Initial Tour of the kitchen An initial tour of the kitchen with the Dietary Supervisor(DS) #1 on 03/14/22 at 12:50 PM revealed the following failed practices: The Walk in Freezer: --Pork Chops box lid was opened and exposing the meat to the elements --Raisin Bread was opened and not labeled with a date --5 Hamburger patties with no open date or use by date The DS indicated the pork chops, raisin bread and hamburger patties needed to be discarded. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards during medication administration by using a barrier with the inhaler for Resident #27, popping a pill into bare hands for Resident #33, not providing hand hygiene to residents prior to a meal and not bagging an inhaler in the drawer of the medication cart for Resident #54. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Resident identifiers: #27, #33 and #54. Facility Census: 54. Findings Included: a) Resident #27 On 03/16/22 at 8:45 AM, Licensed Practical Nurse (LPN) #71 was observed during medication administration. LPN #71 did not use a barrier between Resident #27's nasal spray and the sink. On 03/16/22 at 9:05 AM, LPN #71 stated I'm sorry I was nervous. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to care for a resident in a respectful manner to protect their dignity. Resident #2's urinary catheter drain bag was laying uncovered on the fall and visible from the hallway. This was a random opportunity of discovery. Resident identifiers: # 2. Facility census: 54. Findings Included: a) Resident #2 An observation on 03/15/22 at 2:15 PM found Resident # 2's urinary catheter drain bag was not in a privacy cover and was laying in the floor. During an interview on 03/15/22 at 2:16 PM Licensed Practical Nurse (LPN) #30 acknowledged the urinary catheter bag was uncovered and laying in the floor. On 03/15/22 at 2:37 PM the Director of Nursing (DON) was notified of the urinary catheter bag was not in a privacy cover and the catheter bag was laying on the floor, no further information was provided. .

Inspectors wroteBased on record review and staff interview the facility failed to notify the Physician and the Resident's Medical Power of Attorney (MPOA) timely of a change in the resident's condition for one (1) of one (1) resident reviewed for a change in condition. Resident Identifier #205. Facility census 54.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was complete and accurate. This was true for one (1) of 25 residents reviewed during the survey process. Resident Identifier: #52. Facility Census: 54. Findings Included: a) Resident #52 On 03/16/22 at 11:55 AM, the MDS dated [DATE] section L Oral/Dental Status was reviewed. The section was was coded indicating there were no dental issues. A consultation dated 11/16/21 from a local denture company stated recommend extracting teeth 23, 24, 25, 26 and roots 28 and 29 with an oral surgeon. After a review of the medical record and resident interview on 03/16/22, the resident's teeth and roots had not been extracted as recommended. The resident stated I really want them out . [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan with new interventions after Resident #25 and #205 had additional falls. This was true for two (2) of two (2) residents reviewed during the long-term care survey. Resident identifier #25 and #205. Facility Census: 54. Findings Included: a) Resident #205 A record review found Resident #205 was admitted to the facility 08/20/19. A care plan for risk for falls ., and risk of fracture during falls ., was initiated 08/22/2019, and canceled on 09/23/21 (upon discharge). A review of August 2021 and September 2021 incident reports for Resident #205 found she fell six (6) times (08/02/21, 08/08/21, 08/27/21, 09/01/21, 09/15/21, 09/19/21). The only revision to interventions for the .risk for falls . [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide adequate supervision and interventions to prevent accidents. Resident #205 sustained two (2) falls which resulted in injuries to her head and no interventions were put into place after each fall. This is true for one (1) of 1 resident reviewed for the care area of accidents during the long term care survey process. Resident identifier #205. Facility census 54. Findings Included: A) Resident #205 A review of Resident #205's medical record found she sustained a fall on 08/27/21 at 2:45 am. Resident #205 fell out of bed and sustained a wound to her left forehead that required medical intervention and was transferred to a local hospital for treatment. Resident #205 required sutures to her left forehead and developed a hemotoma. [...]

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to provide necessary respiratory care consistent with professional standards of practice. This was true for one (1) of one (1) residents reviewed for respiratory services during the Long Term Care Survey Process. Resident identifier: #54. Facility Census: 54 Findings Included: a) Resident #54 An observation on 03/14/22 at 4:00 PM, found Resident #54's portable oxygen was set on 2 liters per minute, Activity Supervisor #67 acknowledged it was set on 2 liters per minute. An observation on 03/15/22 at 10:00 AM, Resident #54 oxygen concentrator was not turned on with no oxygen flowing. During an interview on 03/15/22 at 10:00 AM LPN #72 acknowledged the oxygen concentrator was not turned on. On 03/15/22 at 10:03 AM LPN #72 monitored her oxygen saturation at 83. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to ensure medication were labeled in accordance with accepted professional principles. The facility failed to label a bag of intravenous(IV) fluid of Normal Saline and intravenous tubing when it was put into use for Resident #35. This was a random opportunity for discovery. Resident Identifiers: #35. Facility Census: 54. Findings Included: a) Resident #35 An observation on 03/14/22 at 2:50 PM , found a bag of IV fluids was being administered to Resident #35 with no date or order information on the bag or no date on the IV tubing. An interview on 03/14/22 at 2:55 PM, with Licensed Practical Nurse (LPN) # 30, comfirmed (LPN #72's name) is her nurse today she is on lunch. I know that 2 bags of fluids was to be given per report. [...]

Inspectors wroteBased on record review and staff interview the facility failed to keep an accurate medical record for Resident #205 and #37. This is true for two (2) of 25 sampled residents reviewed during the long term care survey process. Resident identifiers #205 and #37. Facility Census 54. Findings Included: a) Resident #205 A review of the medical record found a Progress Note written 09/05/21 at 12:07 am {typed as written} Staff reported that resident was coughing and had a temperature of 102.1 Resident was given a PRN Covid test. Results of test are negative. Gave resident Tylenol 325mg x2 tabs and temperature is now 99. Lung sounds are clear. Will continue to observe resident and report these findings to morning nurse. Resident appears to have yellow drainage from left eye. No redness or swelling to forehead. Stitches are dry and intact. [...]