Meadows of Corsicana, LLC

Inspectors wroteBased on observation, interviews, and record review, the facility did not store, cook, and give out food in a safe and clean way for 1 of 1 kitchen for kitchen task. The facility failed to ensure food safety by not consistently monitoring, discarding, labeling, and storing food items in the refrigerator and storage areas. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection control program for 6 (Resident #56, Resident #47, Resident #51, Resident #21, Resident #35 and Resident #8) of 10 residents reviewed for infection control. 1. CNA D did not conduct hand hygiene between residents (Resident #56, Resident #47, Resident #51, Resident #21, and Resident #35) when passing hallway lunch trays. 2. CNA E did not conduct hand hygiene and glove change when performing peri-care when going from front to back and pulled adult wipes from the package with soiled gloves when providing peri-care for Resident #8. These failures could place the residents at risk of transmission of disease and infection and re-hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that drugs are stored properly, and only authorized persons have access for 1 of 4 medication carts (MC A) reviewed for drug storage and labeling. The facility failed to ensure the F-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure expired milk in the walk-in refrigerator was discarded in a timely manner. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #3) of six residents observed for physician orders for oxygen. The facility failed to provide physician orders for Resident #3, while resident was on oxygen 2 liters via nasal cannula. These failures could place the residents at risk of not receiving necessary care and services that could result to worsen condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #18) of 6 residents reviewed for quality of life. The facility failed to ensure Resident #18 had her fingernails and facial hair trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 for one (Resident #42) of six residents observed for infection control. CNA B failed to perform hand hygiene between glove changes, and when she went from dirty to clean during incontinence care for Resident #42. These failures placed residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent misappropriation of property when Housekeeper A charged Resident #1 $10 for gas to purchase items from the store. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #2). LVN A failed to follow the physician orders for enteral feedings on 09/07/23 at 6:00pm (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #2. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 3 of 17 rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed for environment. The facility failed to repair deep scratches that exposed the sheetrock on the wall behind the head of the bed in room [ROOM NUMBER]. The facility failed to repair crater-like damage on the wall by the recliner in room [ROOM NUMBER]. The facility failed to repair multiple dark reddish stains were on the wall above the bed in room [ROOM NUMBER]. These failures could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 9 residents (Residents #37, #11 and #28) reviewed for PASRR. The facility failed to ensure Residents #37, #11 and #28's PASRR Level 1 screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 17 residents (Resident #21, Resident #39, ad Resident #28) reviewed for care plans. The facility failed to ensure Resident #21's care plan indicated he used oxygen. The facility failed to ensure Resident #39's care plan indicated the proper usage of her grab bar. The facility failed to care plan Resident #28's tracheostomy. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Dented can good were removed from the shelve. 3. Sanitation bucket included the correct sanitation. 4. The ice machine was clean and free from debris. These failures could place residents at risk for cross contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 7 meetings (June 2023, April 2023, March 2023, January 2023, and December 2022) reviewed for QAPI. The facility did not ensure the Infection Control Representative attended their QAPI meetings in June 2023, April 2023, and December 2022. The facility did not ensure the Medical Director attended their QAPI meetings in March 2023 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 5 halls, 1 of 1 dining room, 1 of 1 kitchen, and 2 of 13 (Resident #23 and Resident #27) residents reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 17 residents (Resident #31) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #31's nutritional approaches on the quarterly MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal hand oral hygiene for 1 of 3 residents (Resident #34) reviewed for Activities of Daily Living. The facility did not provide scheduled showers for Resident #34. This failure could place residents at risk of not receiving services/care and a decreased quality of life. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #28) reviewed for activities. The facility failed to provide activities for Resident #28. The facility failed to ensure Resident #28 had activities care planned. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #9) reviewed for pressure ulcers. LVN A failed to follow the physician orders when providing wound care to Resident #9. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 17 residents (Resident #35) reviewed for nutrition. The facility did not ensure dietary recommendations was implemented for Resident #35. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (Hall A/B/room [ROOM NUMBER] nurse medication cart) reviewed for storage of medications. The facility failed to ensure Hall A/B/room [ROOM NUMBER] nurse medication cart was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] D followed the recipe for pureeing the pork loin, green beans, and rice pilaf during the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 3 of 5 staff (LVN A, CNA B, CNA C) reviewed for infection control. The facility failed to ensure CNA B and CNA C appropriately collected soiled linen after removing them from Resident #9's bed. The facility failed to ensure LVN A changed gloves and performed hand hygiene while providing wound care to Resident #9. These failures could place residents and staff at risk for cross-contamination and the spread of infection.