Meadowood a Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide food preparation and storage, as well as maintain kitchen equipment in accordance with professional standards for food safety for the 67 residents who ate facility prepared meals when: 1. One (1) box of carrots in the kitchen freezer was found without an open date;2. One (1) tote of thickener powder was found expired;3. Four (4) non-stick pans were discovered with significant scratches and areas where the non-stick coating was missing and;4. A blender stirring rod was found with deep gouges and broken with a piece of plastic missing. These failures had the potential to put residents at risk for foodborne illnesses and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for a census of 67 when:1. Staff did not wear an isolation gown (protective clothing to prevent transfer of infectious materials) and gloves before entering a designated isolation room (for exposed or suspected residents with infection) of Resident 93;2. Staff did not perform hand hygiene after blood pressure check and proceeded to prepare medications for Resident 42;3. Staff picked up a tablet of aspirin with her bare hands during medication preparation for Resident 65;4. Two pill cutters were found with white pill residues during medication cart inspection. These deficient practices created a potential for cross -contamination and transmission of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 2 sampled residents (Resident 6) using a Continuous Glucose Monitor (CGM - a device that continuously checks a person's blood sugar levels throughout the day and night), when:1. Resident 6 did not have a complete physician order for the use of a CGM;2. There was no process to verify the quality control (a process to make sure something works correctly) and accuracy (being correct) of the device, and;3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions for pressure ulcer (a sore on the skin caused by staying in one position for too long) prevention and treatment were consistent with professional standards of practice for 1 of 23 sampled residents (Resident 94) using a low air loss mattress (LAL - a special mattress that helps prevent and treat bed sores by blowing gentle air through the mattress), when Resident 94's LAL mattress was not set accurately according to the resident's current weight. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 2 sampled residents (Resident 1), using a Continuous Positive Airway Pressure machine (CPAP- a machine that helps a person breathe by gently blowing air through a mask while sleeping), when Resident 1's CPAP pressure settings (the doctor-ordered air pressure level for the CPAP) were not included in the physician's order. This failure had the potential to result in inconsistent implementation of CPAP therapy, improper setup and administration of the CPAP device, ineffective treatment of 1's respiratory condition, delayed recognition of respiratory needs, and an increased risk for respiratory compromise for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that timely medication reordering and adequate medication supply management to ensure medications were available and administered as ordered for 2 of 67 residents (Resident 65 and 8) when:A. Resident 65 did not receive the ordered Lidocaine patch on 6/24/26 due to the medication being unavailable. The resident experienced a pain level of 5 on a scale of 1-10 on her right hip the following day. B. Resident 8 did not receive two of the three ordered doses of Calcium Acetate due to the medication being unavailable. Resident 8 receives dialysis for whom consistent administration of Calcium Acetate is necessary to maintain therapeutic levels. These failures resulted in Resident 65 experiencing pain and placed Resident 8 at risk for reduced medication effectiveness due to missed doses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications, medication-related supplies, and controlled substances were stored, labeled, and maintained in accordance with manufacturer instructions and facility policy for a census of 67 residents when:1. Three sterile packing strips were maintained in opened containers that were not labeled with the date and time opened;2. Multi-resident use of opened 100 mL Normal Saline (NS, salt water) bottles occurred despite the manufacturer's label/instruction, DO NOT REUSE;3. The vault used to store controlled substances awaiting destruction was not permanently affixed to the wall or floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled resident's (Resident 2's) right to be free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) when, Certified Nursing Assistant (CNA) 2 placed tape over the reset button on the call light panel in Resident 2's room, which prevented the call light from working on 3/11/26. This failure had the potential to decrease Resident 2's safety and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled resident's (Resident 3) call lights was functioning properly when Resident 3's call light did not light up outside his bedroom doorway when the call light button was pressed. This failure resulted in Resident 3 experiencing an episode incontinence and put Resident 3 at risk of fall or injury. A review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility in 2025, with diagnoses which included Pneumonia (a lung infection) and lack of coordination. During an interview on 8/14/25, at 10:09 AM, with Family Member (FM)1, FM 1 stated Resident 3's call light was not working from Saturday 8/2/25 through Tuesday 8/5/25. FM 1 further stated Resident 3 pressed his call light but the light above the door did not light up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards of food service safety for eight residents who received soup for lunch on 2/27/25 when there was no temperature recorded for the soup prior to being served to those eight residents. This failure put the eight residents who received soup from the kitchen on 2/27/25 at risk for food borne illness when it was unknown if the soup being served was in the safe temperature zone (above 140 °Fahrenheit to prevent the growth of harmful bacteria).

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 67, when: 1. Signage for Enhanced Barrier Precautions (EBP- a set of infection control measures that use gown and gloves to reduce the spread of multi-drug resistant organisms [MDRO- bacteria that are resistant to many antibiotics] and for people with medical devices that remain in the body for an extended period, providing continuous support or treatment) was not posted on, or near the doorway of Resident 335's room to alert staff to use personal protective equipment (PPE- protective clothing, gown, gloves, or other garments used to prevent the spread of germs) prior to entering the room; and, 2. PPE supplies were not available outside the rooms for Resident 14, Resident 35, Resident 42, and Resident 64 while on EBP. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents rights to be treated with dignity and respect were honored for one of twenty two sampled residents (Resident 38) when Resident 38's meal was placed in front of her, but not fed to her, for greater than 20 minutes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 64) had their rights related to treatment choices known and protected when a copy of Resident 64's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was not kept in Resident 64's record. This failure had the potential to result in Resident 64's preferences for emergent and end of life treatment to not be followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents rights of privacy and confidentiality were honored for one of twenty two sampled residents (Resident 12) when Resident 12's incontinence (lacking control of bowel and bladder) care needs were posted in public view in his room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 12) was free from physical restraint when Resident 12 was unable to independently unbuckle the self-release belt he wore while seated in his wheelchair. This failure had the potential for Resident 12 to experience a lack in freedom of movement, injury, and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 42), had a care plan (a formal process that identifies existing needs and recognizes potential needs or risks) developed to address Resident 42's oxygen needs and use. This failure potentially contributed to Resident 42 not receiving the correct rate of oxygen (liters per minute-LPM. A unit of measure for oxygen delivery).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate urinary catheter (a flexible tube inserted into the bladder used to drain urine) care and services were provided for one of two residents (Resident 71) with urinary catheters in a sample of 22 residents when: 1. Resident 71's urinary catheter bag (a device that attaches to the end of the tube to collect urine) was on the floor; and, 2. Resident 71's urinary catheter bag did not have a dignity cover (a cover that helps maintain the dignity of people who use catheters). These failures had the potential to affect Resident 71's sense of self-worth and self-esteem and placed Resident 71, and others in the facility, at risk for adverse medical outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 8 residents who received oxygen at the facility (Resident 42) when Resident 42's oxygen order was not followed. This failure placed Resident 42 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage - number or ratio expressed as a fraction of 100) with a resident census of 67. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 36 opportunities which resulted in a facility wide medication error rate of 5.55% in 1 of 4 residents (Resident 234 ) observed for medication administration. These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 67 when: 1. Employee's personal items were stored in two of two medication storage rooms (a locked room for storage of medication and supplies); and, 2. Expired medication was available for use in medication cart (a mobile cart containing medications used daily to give medications to the residents) #2, located on the Sequoia unit. These failures may pose unsafe medication use in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain the necessary medications for one of three sampled residents (Resident 1) when Resident 1 ' s Intravenous (IV, in the vein) antibiotic (medication to treat infections) and a pain-relieving medication for migraine headache were not available for use. These failures had the potential to cause prolonged illness for Resident 1 as well as unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 ' s right to be fully informed of her discharge and the possibility for appeal was protected, when Resident 1, who was deemed unable to make health care decisions, signed the notice for her discharge on [DATE] and was discharged on 7/15/24. Resident 1 ' s responsible party (RP) was not provided notice of the discharge appeal process. This failure resulted in Resident 1 ' s responsible party being uninformed of the right to appeal the discharge decision, with the potential that Resident 1 would not receive additional services needed if an appeal was sought and upheld.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure measures were planned and implemented to prevent injury from a fall for one of two sampled residents (Resident 2), when: 1. Resident 2 was at high risk for falling and his care planned interventions did not include measures adequate to prevent an injury if a fall occurred; and, 2. Staff left Resident 2's bed in a high position after Resident 2 fell on 7/2/24, and his revised care plan directed the bed was to be kept low. These failures resulted in Resident 2 sustaining an injury from a fall on 7/2/24 and increased the risk of further falls resulting in serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental care was provided for one of two sampled residents (Resident 1) when Resident 1 had an unwitnessed fall on 7/4/24, which resulted in missing front teeth, and no oral assessment and/or follow-up dental care was provided. This failure led to Resident 1 experiencing pain, difficulty eating, potentially contributed to his weight loss, and had the potential to negatively affect his psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications ordered by the physician were administered to one resident (Resident 1) when dronabinol (a medication used to increase appetite) and vitamin B6 (supplement) were not acquired from the pharmacy in a timely manner. These failures resulted in Resident 1 missing 6 doses of dronabinol and 3 doses of vitamin B6 and had the potential to negatively affect Resident 1 ' s health.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with professional standards of practice on 5/16/23 when, 1a. Licensed Nurse (LN) 3 gave orange juice to Resident 1 for a low blood sugar reading of 59 milligrams per deciliter (mg/dL, units of measure. Normal blood sugar is 70 to 99 mg/dL) instead of physician ' s ordered glucagon gel (a sugary gel used to increase a low blood sugar reading) to increase Resident 1 ' s low blood sugar reading, b. LN 3 did not notify Resident 1 ' s physician of the low blood sugar reading per the physician ' s order, and, c. LN 3 did not recheck Resident 1 ' s blood sugar level every 15 minutes until a blood sugar level of at least 110 mg/dL was reached. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST- a written physician's order that documents the types of medical treatment the resident wants to receive during serious illness, for example, chest compressions if the heart stops beating and/or a tube placed down the throat if breathing stops) was fully completed and/or uploaded to the resident's Electronic Health Record ([EHR]- information stored in the facility's computer system) per facility policy for five of eight sampled residents: 1. Resident 6 2. Resident 25 3. Resident 54 4. Resident 275 5. Resident 276 These failures could have resulted in a delay in treatment during a medical emergency and/or the incorrect life sustaining treatment administered to the Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 6) was treated with dignity, when the facility failed to replace Resident 6's missing upper dentures, leaving Resident 6 without her upper dentures for over one month. This failure resulted in Resident 6 requiring a change in the texture of her diet (in order to eat without upper teeth) and resulted in Resident 6 self-isolating from other residents due to embarrassment of missing teeth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean environment for two of 20 sampled Residents (Residents 26 and 30) when the fall mats beside their beds were soiled and torn. This failure had the potential to cause infection for Residents 26 and 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy per its policy for one of two sampled residents (Resident 28) on oxygen therapy, when Resident 28's oxygen tubing had not been changed for 17 days. This failure had the potential to lead to respiratory infection for Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of five errors out of 32 opportunities, which resulted in a facility wide medication error rate of 15.6%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The five medication errors were identified in two residents (Resident 35 and Resident 175) out of eight residents observed for medication administration observation as follows: 1. Resident 35's medications were crushed and mixed in one cup for Tube Feeding (TF, a way to provide nutrition and medications when one cannot eat or drink safely by mouth. The tube is surgically inserted into the stomach) administration; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and used according to the manufacture specifications for a census of 74 when: 1. The medication cart (a wheeled cart that stores medications given to residents on daily basis) in Sequoia station contained medications not dated upon opening; and, 2. The medication cart in Harmony station contained medications not dated upon opening. These failures could result in unsafe medication use in the facility and ineffective medication treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 6) had a referral to a dentist following the loss of Resident 6's upper dentures shortly after admission to the facility. This failure resulted in Resident 6 being without upper dentures for over a month and affected Resident 6's quality of life.

Inspectors wroteBased on observations during the initial tour of the kitchen, interview, and record review, the facility failed to follow its policy and procedure for safe storage of food when: 1. Staff was not wearing a hair covering; and, 2. Expired food was available for consumption These failures had the potential to lead to contamination of food for all 74 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document in the electronic health record (EHR) for one of twenty sampled residents (Resident 6) when, there was no documentation on the measures taken by the facility to replace Resident 6's missing upper dentures. This failure had the potential to result in staff being unaware of Resident 6's missing upper dentures with the delay in documentation.