Meadows Ridge Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure prescribed medication was administered in accordance with the physician's orders for one of four sampled residents (Resident 1) when Resident 1 had an order to received Phenytoin (medication for seizures - a sudden movement of electrical activity in the brain causing shaking of the limbs and stiffening of the body) and was not administered from June 7, 2026, to June 17, 2026 (a total of 19 doses). This failure resulted in Resident 1 being transferred to an acute care hospital after experiencing seizure activity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of destroyed medications when nine (9) medications that were disposed were found with missing witness signature from the second licensed nurse for one of one sampled Medication Disposition Record/Pass Log (document used to record the destruction of a medication for tracking purposes). This failure had the potential to have prescription medication available for staff use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illness when:1a. There were three clean dishes found to have green and brown food debris, brown grease buildup, remnants of lettuce leaf, and crumbs inside it, when stored under a food prep table in the kitchen.1b. A storage shelf under a food prep table had a white dried substance and greasy black substance with food crumbs on it where clean dishware was kept.2. Eight (8) plastic cups containing a white colored liquid which resembled milk were found in the refrigerator with no date label. These failures had the potential to result in food contamination and foodborne illness to a population of 84 medically compromised residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when:1. Resident 7's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated per facility's policy and procedure (P&P). 2. One laptop mounted to an Intravenous (IV) cart (a mobile cart used by licensed nurses to store and transport medication and supplies) was found visibly soiled, with dried white substance on it, on unit one outside nursing station.3. Resident 11's Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) protocol were not followed in accordance with facility's P&P.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's right were followed for one of three sample residents (Resident 7) when Resident 7 was administered lorazepam ( medication used to treat short-term anxiety, panic attacks, and sleep problems) without being informed in advance of the risks and benefits of the medication, the treatment alternatives or other options. This failure resulted in Resident 7 not being fully informed about the care and treatment provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to one of one resident (Resident 56) when on January 25, 2026, Resident 56 left the facility without staff being aware. Resident 56 was found down the street from the facility in a parking lot near a gas station. This failure had the potential to result in harm to Resident 56 who was at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one of one resident (Resident 88) investigated for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when:a. There was no documented evidence staff performed assessment of Resident 88's dialysis access site every nursing shift (day, evening, and night shift) as ordered by the physician.b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of two residents (Resident 1), when Resident 1 requested her medical records but were not provided within 48 hours of the request as per the facility's policy. This failure resulted in a violation of Resident 1's right to have access to medical records as requested by Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure that appropriate procedures were followed after an unwitnessed fall of one of four sampled resident (Resident 1). There was no documentation of the fall, physician notification, and no indication that Resident 1 was monitored following the incident. This failure had the potential for Resident 1's overall medical condition to decline and go undetected by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure for Administering Medications for one of four sampled residents (Resident 4) when licensed staff did not monitor Resident 4's blood pressure and heart rate every six hours as ordered by resident 4's physician and give Hydralazine (medication to treat high blood pressure) as needed. This failure resulted in Resident 4 a clinically compromised resident being sent to the hospital for evaluation and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from financial exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) by a staff member. This failure had the potential to cause significant emotional and financial harm to Resident 1 and had the potential to place other residents at risk of abuse, neglect and exploitation.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when personal hygiene was not provide as needed and failing to notify responsible party (RP) of Resident 1 ' s shower refusals. This failure has potential in putting Resident 1 ' s health and safety at risk when hygiene needs were not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, when: 1. On October 1, 2024, two unopened one-pound bags of mini marshmallows, with an expiration date of August 8, 2024, were found stored on top of a shelf in the dry storage room and was available for use. 2. On October 1, 2024, one 4 oz (ounce- a unit for measuring liquid) cup of apple juice and one 4 oz cup of cranberry juice, with the date September 29, 2024, were found on Resident 51's bedside table and were available for consumption. These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food or beverages) for 84 vulnerable residents receiving food from the facility's kitchen.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that Significant Change of Status Assessments (SCSA- required when a resident's condition has significantly changed, either improving or declining, and the change is expected to last longer than two weeks) of the Minimum Data Set (MDS- federally mandated assessment tool) were completed within 14 days for one of three residents reviewed for pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)(Resident 39) when Resident 39 had a significant decline in her condition due to severe weight loss and changes in the stage (a system used to classify severity) of her pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight residents reviewed for Range of Motion (ROM- full movement potential of a joint) (Resident 39) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM when Resident 39's Restorative Nursing Assistant (RNA- help residents improve and maintain their physical abilities and ADLs, and prevent further decline) orders were not carried out in a timely manner. This failure could have potentially caused a delay of preventing severe contractures (a medical condition characterized by the shortening and hardening of muscles, tendons, or connective tissues, which can lead to stiffness and restricted movement in joints) of all extremities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with prescriber's orders and facility policy for one resident reviewed for use of antibiotic (medication used to treat bacterial infections) (Resident 39). This failure had the potential to make the antibiotic less effective and prolong the course of treatment, placing Resident 39's health at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents reviewed for nutrition (Resident 39) received a diet prescribed by their physician in a timely manner. This failure had the potential to place Resident 39 at risk for further nutrition and medical decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control prevention were implemented among a highly vulnerable population of 86 residents, when an oxygen tubing (thin plastic tube that connects a machine, which makes extra oxygen to a person's nose) and related oxygen supplies were not replaced in accordance with the facility's policy and procedure for one of five residents reviewed for oxygen (Resident 34). This failure has the potential to cause and increased risk of infection to Resident 34 due to prolonged use of respiratory equipment without proper replacement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a certified nursing assistant was able to demonstrate competency in skills and techniques for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) did not report Resident 1's redness on the nose to a licensed nurse. This failure had the potential to result in delayed treatment and care for Resident 1, placing Resident 1 ' s health at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided in accordance with resident needs and safely for one of 3 Residents (Resident 1) when: 1. Resident 1 acquired an open wound to right hand pinkie finger. 2. No wound dressing as ordered noted on pinkie finger open wound. 3. No wound care treatment as per Treatment Record for September 23, 2024. This failure resulted in a clinically compromised resident, (Resident 1) health and safety at risk, when the developed in facility and wound was exposed with possibility for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision, monitoring, and implementation of interventions were enforced for one of three sampled residents (Resident 1) when Resident 1's whereabouts were not monitored and documented in accordance with the physician's orders and care plan after Resident 1 had an altercation with another resident on June 11, 2024. This failure had the potential for Resident 1 to have an increased risk of further altercation which could place him at risk of injuries and bodily harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for two of three sampled residents (Resident 1 and 2). This failure had the potential to place a clinically compromised Residents (Resident 1 and 2) safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for six of seven sampled residents (Resident 1,2, 3,4,5, and 6). This failure had the potential to place a clinically compromised Residents (Resident 1,2, 3,4,5, and 6) health and safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure the care plan (a summary of a resident's health conditions, specific care needs, and current treatments) was implemented for one of three sampled residents (Resident 3) when Resident 3's care plan intervention for psychology consult was not implemented after an alleged abuse was reported by Resident 3 on January 30, 2024. This failure had the potential to cause a delay in identifying Resident 3's psychological need, immediate care and support needs which could place her mental and psychosocial well-being at the higher risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The top of the mixer and the coffee maker were dusty, which had the potential to contaminate the food and coffee with dust. 2. The floors under the center island and behind the ice machine had food crumbs and trash, which had the potential to attract microorganism carrying pests. 3. Two plastic four-quart containers were stacked and stored wet, which had the potential for bacteria (can cause disease) growth. 4. Two metal pans, which stored clean utensils, had liners with food crumbs under the liners, which had the potential to attract microorganism carrying pests and contaminate the clean utensils 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not properly dispose (get rid of by throwing away) of trash when the outside dumpster area had gloves, trash, and rotten (decomposing or break down) food on the ground. This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 81 medically compromised residents.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of a Coronavirus, COVID-19 (a highly contagious respiratory infection) when: 1. Resident 389 was observed not following proper personal protective equipment (PPE) guidelines when Resident was in yellow zone (Residents under isolation observation for suspected COVID-19). 2. The COVID-19 screening forms (forms that are used to screen individuals for COVID-19 symptoms prior to entry into the facility) were not completed on the visitor's COVID-19 screening forms before entering the facility. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Advance Directives (A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), were completed for nine sampled residents (Residents 25, 432, 389, 77, 55, 58, 81, 61 and 75). This failure had the potential to result in a delay of treatment for the residents as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for five of 21 sampled residents (Resident 4, 9, 14, 24, 73), when range of motion exercises, splints and hand rolls were not provided as per physician orders. This failure had the potential to decrease in the range of motion and could have resulted in worsening of contractures (joint stiffness) and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two of 81 residents (Resident 75 and Resident 58) when: 1. Resident 75 lost 16% of her body weight from January 14th, 2022, to April 2, 2022. Her gastrostomy tube (GT- a tube placed through abdominal wall through which liquid nourishment and medications are administered) feeding rate was calculated on her adjusted body weight (adj bw) (calculation used to calculate energy needs for overweight or obese people who want to lose weight) of 56.6 kilograms (equals 124.5 pounds) which was 40 pounds less than her actual body weight. 2 Resident 58 lost 13% of his body weight in 3 months from January 2022 to April 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their daily menu for lunch when, on April 5, 2022, at 12:45 PM, the [NAME] 1 did not prepare the puree (food that is blended until it is a thick, smooth, lump-free consistency) diet lunch correctly. The [NAME] 1 pureed regular bread for the puree diets but should have pureed garlic bread. 17 Residents received the puree diet. This failure had the potential for residents to lose their appetite and compromise the nutritional status of 17 out of 78 Residents

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program for two residents' rooms (room [ROOM NUMBER] bed 2, and 305 bed 2), when several small flies were observed flying in room [ROOM NUMBER] bed-2's ceiling and by bedside table, and flies observed in room [ROOM NUMBER] bed 2 on the walls and ceiling. These failures had the potential to cause irritation to residents' skin and could spread infectious bacteria to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of one sampled resident (Resident 11) when Resident 11's urinary catheter (flexible tube inserted into the bladder to drain urine) bag, was not covered by a dignity bag. This failure had the potential to compromise Resident 11's dignity and violate his right to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious.

Inspectors wroteBased on interviews and closed record review, the facility did not ensure that one of three closed record sampled residents (Resident A) had orthostatic blood pressures (Blood pressure is taken, lying, sitting, and standing to determine if there is a drop with position change) or do vital signs (temperature, pulse, respiration and blood pressure) every four hours as well as, the oxygen saturation level as ordered by the physician. This failure resulted in resident being transferred to a hospital (a higher level of care).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure adequate supervision was provided for one Resident (Resident 56), when the facility did not implement intervention (floor mat) to prevent future falls as indicated in the care plan and the physician orders. This failure had the potential to result in future falls and increase the risk of injury related to falls.

Inspectors wroteBased on interview, and record review, the facility failed to ensure glucometer (device used to measure sugar levels in blood) calibration monitoring were complete for three of three nursing units (Unit 1, 2 and 3). These failures had the potential to get inaccurate blood glucose results for 20 residents receiving insulin.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for three of three medication carts (Carts 1, 2 and 3). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff.

Inspectors wroteBased on observation, interview, and record review, the facility did not accommodate one of 78 residents (Resident 387) preferences on a vegetarian diet (a diet that does not include any meat, poultry, or seafood) by not having a vegetarian menu available. This failure had the potential for Resident 387 to have a compromised nutritional status due to not eating a varied (a number of different types) and nutritionally balanced (the correct number of calories and nutrients) vegetarian diet due to the facility not having a vegetarian menu planned a week in advance.