Meadowlark Hills

Inspectors wroteThe facility had a census of 117 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one of one facility kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 117 residents. The sample included 25 residents, with five reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidelines from the Centers for Disease Control and Prevention (CDC) when they failed to offer and administer or obtain an informed declination, or a physician-documented contraindication for Resident (R) 36, R63, R70, R80, and R85, pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

Inspectors wroteThe facility had a census of 117 residents. The sample included 25 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 35 and R5 with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 117 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to include a hospice (a program that gives special care to people who are near the end of life) service visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 69. This deficient practice placed the resident at risk of not receiving resident-directed end-of-life care.

Inspectors wroteThe facility had a census of 117 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to maintain standardized infection control practices during a dressing change for Resident (R) 26. This placed the resident at increased risk of wound infection.

Inspectors wroteThe facility had a census of 119 residents, with three residents sampled. Based on record review and interview, the facility failed to ensure Resident (R) 1 was secured with the safety belt in a mechanical spa lift chair, during a transfer out of a spa tub. This deficient practice resulted in R1 falling from the spa lift chair and R1 sustained a fractured (broken bone) right femur (thigh bone).

Inspectors wroteThe facility identified a census of 121 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from misappropriation when Licensed Nurse (LN) G, on 02/11/24 at 06:57 PM, emptied R1's promethazine (medication used to prevent and treat nausea and vomiting) with codeine (narcotic pain medication) liquid into a water bottle and put it in her purse then left the facility with it. This deficient practice placed R1 at risk for missed medications and further misappropriation of medications.

Inspectors wroteThe facility had a census of 120 residents. Based on observation, interview, and record review the facility failed to serve food in a sanitary manner for residents in one of seven households. This deficient practice placed the 22 residents of the household at risk for food borne illness.

Inspectors wrote- R106's Electronic Medical record (EMR) documented diagnoses of congestive heart failure (CHF-a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), end stage renal disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for dialysis or a transplant), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R106 required supervision for dressing and was independent with all other activities of daily living. The Nutrition Care Plan, dated 04/25/23, directed staff to obtain the resident's weight on non-dialysis (procedure where impurities or wastes were removed from the blood) days. [...]

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents. Based on observation, recrod review, and interview, the facility failed to provide a clean environment for two sampled residents, Resident (R) 66 and R7, who had wheelchairs which were soiled with dried food particles. This placed the affected residents at risk for impaired comfort and/or dignity.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman (LTCO) when Resident(R) 53 discharged to the hospital. This placed the resident at risk for decreased autonomy and quality of life.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to develop an individualized comprehensive person-centered care plan related to Resident (R)26's aspiration (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) risk and R71's dialysis (procedure of removing extra fluid and waste product from the blood) treatment which placed R26 and R71 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin tears for one sampled resident, Resident (R) 66, who received skin tears during cares. This placed R66 at risk for further injury due to uncommunicated and/or unmet care needs.

Inspectors wroteThe facility has a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to identify and respond to daily weight variances for Resident (R) 55 and R106, and failed to identify implement preventative measures to prevent skin tears for R66. This placed the residents at risk for physical complications, decline and pain.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents with 14 residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment for Resident (R)8 who fell from her electric lift recliner during a self-transfer, and R16 who had multiple falls with staff in which the facility failed to identify the need for increased staff assistance. These deficient practices placed the residents at risk for falls and related injuries.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents, with two reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor hydration status for Resident (R) 55, who was on a physician ordered fluid restriction. This placed the residents at risk for dehydration or fluid overload.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents with two reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R)71, who received dialysis treatment. This placed the resident at risk for complications and health decline.

Inspectors wroteThe facility had a census of 120 resident. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to ensure a system to review and respond to the Consultant Pharmacist's (CP) repeated recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) for Resident (R) 84 and R66 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication which placed the R84 and R66 at risk of adverse side effects associated with psycotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review and interview the facility failed to hold diuretic medications multiple times for blood pressure readings outside of physician ordered parameters for Resident (R)26, which placed the resident at risk for continued low blood pressure.

Inspectors wroteThe facility had a census of 120 resident. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) for Resident (R) 84 and R66 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication which placed the R84 and R66 at risk of adverse side effects of psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 120 residents and identified four medication rooms. Based on observation, recrod review, and interview the facility failed to ensure expired medications were disposed of in a timely manner. This deficient practice placed residents at risk to receive ineffective medication.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of Resident (R) 47's heart medications held numerous times due to blood pressure or heart rate below physician ordered parameters, and R28's blood pressures out of physician ordered parameters.

Inspectors wroteThe facility had a census of 127 residents. Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents that resided in two of the seven households in the facility.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to notify the Ombudsman for one sampled resident discharged to the hospital, Resident (R) 126.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to update and revise the care plan for one of three residents reviewed for pressure ulcers, Resident (R) 63.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate interventions according to the standards of care to prevent the development of heel pressure ulcers (localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 63 who was at risk for pressure ulcers.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistance to prevent accidents for one sampled resident, Resident (R) 28.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility's consultant pharmacist failed to notify the Director of Nursing, medical director, or physician the lack of a stop date for Resident (R) 47's PRN psychotropic medication, medications held numerous times due to blood pressure or heart rate below physician ordered parameters, and medications administered when blood pressure or heart rate were below physician ordered parameters. The facility's consultant pharmacist also failed to address the lack of physician notification for R28's blood pressures out of physician ordered parameters.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to hold medications when blood pressure and/or pulse were below physician ordered parameters for one sampled resident, Resident (R) 47.

Inspectors wroteThe facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a stop date for a PRN (as needed) psychotropic medication (medications that affect a person's mental state) for one of five sampled residents, Resident (R) 47.