Meadowview Health & Rehab Center

Inspectors wroteBased on record review and interview the facility failed to ensure residents were free from psychosocial harm and physical restraints used for the purpose of discipline or convenience that were not required to treat the residents' medical conditions for 2 (#1, #2) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to ensure staff reported alleged violations of abuse for the use of physical restraints to the administrator immediately or within 2 hours for 2 (#1, #2) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record review, observation and interviews the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure oral care was provided for 1(#2) of 3 sampled residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#3) of 3 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was seen face to face by a physician at least once every 60 days for 1 (#1) of 3 sampled records reviewed.

Inspectors wroteBased on record reviews and interviews the provider failed to ensure ADL (Activities of Daily Living) Care was completed for 1 (Resident #1) of 3 sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure 1 (#1) of 13 sampled residents reviewed was free from unnecessary drugs. The facility failed to monitor Resident #1's edema while receiving a diuretic.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation for 1 (#1) of 3 sampled residents reviewed to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide Resident #1 with a discharge instruction form.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure 1 (#2) out of 3 sampled residents reviewed received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers. The facility failed to: 1. Complete a head to toe assessment prior to discharge to hospital, and 2. Notify staff of change in skin status/injury.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers 1 (#1) of 3 (#1, #2, #3) residents reviewed for pressure ulcers. The facility failed to have documented evidence of turning and repositioning resident #1 to help prevent pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state agency for 1 (#2) of 2 (#1 and #2) residents sampled with facility incident reports.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#2) of 5 (#1, #2, #3, #4, and #5) sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#2) of 3 (#2, #4, and #5) residents reviewed for accidents. The facility failed to ensure fall risk assessments were completed quarterly, specific interventions were implemented based on the results of the risk assessments, and careplan interventions were implemented on readmission on [DATE].

Inspectors wroteBased on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental, and psychological well-being of each resident for 1 (#2) of 3 (#2, #4, and #5) residents sampled for accidents. The facility`s failed practice was evidenced by a Certified Nurse Aide's (CNA) failure to follow the facility's Incident/Accident policy and procedure when resident #2 was found on the floor on 08/06/2024.

Inspectors wroteResident #98 Based on record review and interviews the facility failed ensure a discharge assessment was completed for 1 (Resident #98) of 4 (Residents #6, #98, #103, #106) residents reviewed for hospitalizations.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 (#102,#118) of 3 (#10, #102,#118) residents reviewed for position and mobility. The facility failed to apply splints for Resident #102 and Resident #118 as ordered. Resident #102 Review of Resident #102's Medical Records revealed an admit date of 10/12/2023 with the following diagnoses, in part: anoxic brain damage/not elsewhere classified, muscle wasting and atrophy/right upper arm/left upper arm, contracture of muscle, and personal history of sudden cardiac arrest. [...]

Inspectors wroteBased on record review, observation, and interviews the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding by failing to change enteral feeding container at appropriate interval for 1 (#37) out of 3 (#37, #42, #67) residents reviewed for tube feedings.

Inspectors wroteBased on record review and interview, the facility failed to ensure a performance review had been completed at least every 12 months for 3 (S5CNA [Certified Nursing Assistant], S6CNA, S7CNA) of 5 (S5CNA, S6CNA, S7CNA, S8CNA, S10CNA) personnel records reviewed.

Inspectors wroteBased on record review, observations and interviews the facility failed to accommodate the needs of 1 (#38) of 39 sampled residents. The facility failed to ensure Resident #38 had a call light within reach.

Inspectors wroteBased on observation and interview the facility failed to ensure garbage was disposed properly.

Inspectors wroteBased on record review and interviews the facility failed to ensure adequate supervision and assistance was provided to prevent accidents. The facility failed to implement the plan of care for 1(#57) of 4(#27, #57, #102, #104) residents reviewed for accidents.

Inspectors wroteBased on observation and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary condition by having a leak in the apple juice concentrate tubing of the drink station. This had the potential to affect 118 residents who received meals from the kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure alleged violations of abuse and misappropriation of resident property were reported no later than 24 hours to the State Survey Agency for 2 (#32 and #36) of 3 (#32, #36, #104) residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to thoroughly investigate an allegation of misappropriation of funds/exploitation for 1 (#36) of 3 (#32, #36, #104) sampled residents reviewed for abuse.

Inspectors wroteBased on observations, interviews and record review the facility failed to accommodate the needs and preferences for 2 (#67, #119) of 5 (#61, #67, #72, #119, #233) residents reviewed for accidents. The facility failed to ensure: 1. Resident #67's wheelchair had leg rests in place. 2. Resident #119's right hand assist rail was tightly secured to the bedframe and the left hand assist rail was not present.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the plan of care was followed for 2 (#51 and #101) of 3 (#51, #94, #101) residents reviewed for position and mobility. The facility failed to ensure residents #51 and #101 wore splint devices according to their plan of care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the plan of care was revised for 1 (#51) of 3 (#51, #94, #133) residents reviewed for hospitalizations. The facility failed to ensure resident #51's plan of care was revised to reflect new onset seizures.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good grooming, and personal hygiene for 3 (#95, #101, #234) of 3 (#95, #101, #234) residents observed for ADL care in a total sample of 49 residents. The facility failed to (1) ensure Resident # 101 and Resident #234's fingernails were trimmed and clean, and (2) Resident #95's face was clean.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure adequate supervision was provided for 1 (#72) of 5 (#61, #67, #72, #119, #233) residents reviewed for accidents. The facility failed to conduct an elopement assessment utilizing the Wander Data Collection Tool each quarter for Resident #72, as per facility policy.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure a resident being fed by enteral means received the appropriate treatment and services by failing to label a resident's feeding bag properly according to facility policy for 2 (#21, #55) of 2 (#21, #55) resident's reviewed for tube feeding.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by: 1.) Having food items in the dry pantry that were not labeled with date when opened. 2.) Having food items in the dry pantry that contained insects. 3.) Failing to ensure dishwasher was in proper working order through temperature/chemical check. This had the potential to affect 89 resident who received trays out of the kitchen as per S11 Dietary Manager.