Meadowbrook at Bloomer

Inspectors wroteBased on observation, interview and record review the facility did not store, prepare, or serve food in a sanitary manner. This has the potential to affect all 30 residents. ~Staff did not consistently perform hand washing during food service.~Staff did not consistently take temperatures prior to food service.~Staff did not store cold and frozen foods in a timely manner after receiving food delivery.~Surveyor observed refrigerator/freezer logs incomplete on 3 separate units.~Surveyor observed ice scoop cleaning logs not complete.~Surveyor noted dishwasher temperature logs not complete.~Surveyor observed an open gallon of milk without a date on it.~Surveyor observed tray line service audit (food temps) incomplete.~Surveyor observed [NAME] F not wearing a beard restraint. ~Surveyor observed [NAME] F touching ready to eat foods with contaminated gloves.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff wore appropriate personal protective equipment (PPE) while handling soiled linens and laundry. This has the potential to affect 30 out of 30 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure 5 of 5 residents (R5, R7, R11, R13, & R35) or the residents' legal representatives were notified of the resident's reason for transfer/discharge in writing to the resident and their representative, notify the ombudsman of the transfer and 3 of 5 residents (R5, R7 and R11) did not receive a bed hold. R5 was transferred from the facility, and no notice of transfer was given. R5 did not have a bed hold given. R7 was transferred from the facility, no notice of transfer or bed hold was given on 1/16/26 and no reason for transfer was listed on the notice of transfer on 1/12/26. R13's notice of transfer documentation was missing the date, location R13 was transferring to and reason for the transfer. R11's notice of transfer was missing the date, R11's name, location of transfer and reason for transfer. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASARR) process for 1 of 2 residents (R1) reviewed for PASARR screening. R1 did not have a PASARR level II (2) completed.

Inspectors wroteBased on record review and interview, the facility did not ensure that trauma informed care was provided in accordance with professional standards of practice and account for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 2 residents (R11) reviewed for Post Traumatic Stress disorder (PTSD). R11's care plan did not provide individualized interventions based on the triggers noted in R11's trauma informed assessment.

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This occurred for 1 of 1 medication storage rooms observed. Surveyor observed control medication Lorazepam not double locked in a permanently affixed compartment.

Inspectors wroteBased on observation, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 25 residents. Dietary Aide (DA) G did not allow the thermometer probe to air dry of alcohol prior to inserting into glasses of milk and juice intended to be served to residents for breakfast. Resident foods that were brought in were not labeled with resident names/dates and disposed of in a manner to prevent illness. DA G was observed with her shirt, which had been sprayed with water and food debris, putting away clean dishes in a manner that contaminated the clean dishes. DA G put the clean dishes away when still saturated with water. This is evidenced by: Example 1: Surveyor reviewed the facility policy titled, Thermometer, dated February 2020. The policy, in part, read: Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an 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. This has the potential to affect all 25 residents (R). -Residents with infection symptoms not placed on proper precautions. -Observations of Certified Nursing Assistants (CNA) not donning Personal Protective Equipment (PPE) and providing proper hand hygiene prior to entering/exiting rooms for residents on precautions. Certified Nursing Assistant (CNA) C did not wear her surgical mask in a manner (above her nose) to prevent the spread of infection during a facility outbreak of respiratory illness, covid 19 and gastrointestinal illness (GI). [...]

Inspectors wroteBased on interview and record review, the facility did not report 1 of 3 residents' (R), R131, allegations of exploitation to the State Survey Agency via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident.

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 1 of 12 sampled residents (R) reviewed. (R18) -The MDS assessments are coded in error stating that a Preadmission Screening and Resident Review (PASARR) level 2 screen had not been completed when it was completed at the time of assessment for R18.

Inspectors wroteBased on interview and record review, the facility failed to provide interventions in the comprehensive care plan to mitigate re-traumatization for 1 of 1 resident (R18) reviewed for Post Traumatic Stress Disorder (PTSD). -Staff were not aware there was a resident with PTSD. R18's PTSD care plan did not indicate triggers and specific interventions related to loud noises.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 5 of 5 residents (R1, R2, R4, R5, and R6). R1 experienced a fall after staff did not appropriately place sling for mechanical lift transfer. The facility did not ensure all direct care staff were educated on proper sling placement to ensure all other residents requiring a mechanical lift transfer, did not sustain a fall or injury during a transfer.

Inspectors wroteBased on observation, interview and record review, the facility failed to store prepare and distribute food under sanitary conditions this has the ability to affect 21 of the facility's 22 residents. Low temperature chemical sanitization dish machine is used but the facility has no monitoring system in place to monitor the machine to ensure proper chemical sanitization occurs. Beard restraints were not always worn during food preparation. Oscillating fan on kitchen wall is dirty and blows towards food preparation areas. This is evidenced by: The facility policy, entitled Dishwashing Temperature Log, dated February 2020, states in part: For low temperature (chemical sanitizing) machines, concentration of sanitizer must be recorded on form. The facility policy, entitled Personal Cleanliness and Hygienic Practices, dated February 2020, states in part: [...]

Inspectors wroteBased on interviews and record review, the facility failed to submit complete and accurate data to the Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for quarter four of 2023 (July 1 - September 30). This has the potential to affect all 22 residents. This is evidenced by: Surveyor noted during survey preparation that the facility triggered for failing to have licensed nursing coverage 24 hours each day for the dates of: 07/08/23 (Saturday), 07/09/23 (Sunday), 07/22/2023 (Saturday), 08/05/2023 (Saturday), 08/06/2023 (Sunday), 09/02/23 (Saturday), 09/03/23 (Sunday), 09/04/23 (Monday), 09/16/23 (Saturday), 09/30/23 (Saturday). On 03/05/24 at 11:18 AM, Surveyor spoke with Nursing Home Administrator (NHA) A and Corporate Human Resources Director (CHRD) H regarding the nursing coverage for the months of July, August, and September of the 2023 year. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an 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 did not a have a clear water management process or plan in effect with control measures to prevent transmission of Legionella infection. This has potential to effect 22 of 22 residents (R).