Meridian Meadows Transitional Care

Inspectors wroteBased on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of that treatment. This was true for 1 of 6 residents (Resident #5) whose records were reviewed for informed consent. This failure created the potential for miscommunication and adverse effects when Resident #5 was not informed in advance of the risks and benefits of the ordered medication.

Inspectors wroteBased on observation, policy review, resident interview, and staff interviews, it was determined the facility failed to ensure an interdisciplinary team assessment, physician orders, or care plan documentation were in place for self administration of glucose tablets. This was true for 1 of 3 residents (Resident #15), whose record was reviewed for medication administration. This failure created the potential for harm when unsafe medication practices and unmonitored treatment of hypoglycemia were identified.

Inspectors wroteBased on observation, policy review, and staff interview it was determined the facility failed to assess a resident for safety related to bed rail use or informed consent was obtained prior to use of the bed rail. This was true for 1 of 1 resident (Resident #18) reviewed for restraint assessment. This deficient practice had the potential for physical and psychosocial harm if Resident #18 were injured, trapped, or felt she was being restrained unnecessarily.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure resident care plans accurately reflected the use of assistive devices. This was true for 1 of 16 residents (Resident #18) reviewed for comprehensive person-centered care plans. This failure had the potential to result in unmet care needs and increased risk to resident safety.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 16 residents (Resident #4) reviewed for professional standards of practice. This failure created the potential for harm if Resident #4 were to receive oral medications despite having difficulty swallowing.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were dependent on staff for activities of daily living assistance received services for their fingernails. This was true for 1 of 1 residents (Resident #50) reviewed for nail care. This placed Resident #50 at risk of embarrassment which could affect him socially due to the appearance of his fingernails.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure residents had an active physician's order. This was true for 1 of 16 residents (Resident #15) whose record was reviewed for quality of care. This deficient practice created the potential for adverse outcomes when Resident #15 self-administered a medication not ordered by a physician.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure wound care was provided according to physician orders and acceptable standards of practice. This was true for 1 of 1 residents (Resident #5) observed for wound treatment. This failure created the potential for delayed healing and wound deterioration.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders. This was true for 1 of 1 residents (Resident #1) reviewed for oxygen therapy. This deficient practice created the potential for adverse outcomes if residents' did not receive the proper amount of oxygen.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were free from duplicate medication orders and side effect monitors were in place. This was true for 2 of 6 residents (#2 and #5) whose records were reviewed for unnecessary medications. This failure placed Resident #2 at risk for overmedication and Resident #5 at risk for their needs to go unmet when they were not monitored for side effects of their medications.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents and failed to securely store medications. This was true for 1 of 3 medication carts (West Wing Cart) inspected for expired medications and true for 1 of 1 residents (Resident #4) reviewed for storage of self-administered medications. These failures created the potential for residents to receive expired medications with decreased efficacy and created the potential for harm to residents if they were to obtain medications which were left unsecured.

Inspectors wroteBased on record review, SOM Appendix PP, and staff interview, it was determined the facility failed to keep complete hospice records on file at the facility for residents receiving hospice services. This was true for 1 of 3 residents (Resident #18) whose record was reviewed for accuracy and completeness. This deficient practice created the potential for harm if hospice paperwork did not confirm Resident #18 agreed to receive hospice services.

Inspectors wroteBased on record and policy review, and staff interview, it was determined the facility failed to implement a performance improvement plan (PIP) for a systemic concern related to staffing. This deficient practice created the potential for harm if residents received substandard quality of care if staffing concerns were not identified and responded to accordingly.

Inspectors wroteBased on observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene during medication administration or wound care, did not follow proper wound care protocol, and did not sanitize reusable medical equipment. This was true for 2 of 5 residents (#10 and #27) observed for medication administration and for 1 of 1 residents (Resident #5) observed for wound care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on record and policy review, SOM Appendix PP, and staff interview, it was determined the facility failed to educate residents on the risks and benefits of pneumococcal and influenza immunizations. This was true for 3 of 5 residents (#4, #8, and #36) whose records were reviewed for current immunizations. This deficient practice created the potential for harm if residents were not educated about the risk and benefits of receiving or declining the pneumococcal and influenza immunizations.

Inspectors wroteBased on record and policy review, and staff interview, it was determined the facility failed to document if the COVID-19 vaccine was offered to residents. This was true for 2 of 5 residents (#4 and #8) reviewed for COVID-19 vaccination. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination.

Inspectors wroteBased on record review, staff interviews, and review of the Long-Term Care Reporting Portal, it was determined that the facility failed to ensure residents were free from neglect. This was true for 3 of 6 residents ( #3, #10, and #20) whose records were reviewed for abuse and neglect. This failure resulted in harm when Resident #3 was injured during a transfer and created the potential for embarrassment and psychosocial harm when Resident #10 and Resident #20 were not provided timely incontinence care.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure allegations of neglect were reported to the State Agency within the regulated time period. This was true for 2 of 6 residents, (#3, and #10) who were reviewed for abuse and neglect. This failure had the potential to affect all residents in the facility and placed them at risk for harm related to neglect. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (a condition that occurs when the blood flow to part of the brain is obstructed), hemiplegia (paralysis or weakness on one side of the body), and major depressive disorder. A review of the facility's Incidents and Accidents (I&A) record dated 3/31/25 documented that Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell, landing on her left arm. [...]

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 3 medication carts observed in the facility. This failed practice created the potential for harm if an unauthorized person obtained medications left unattended and unsecured by staff.

Inspectors wroteBased on observation, review of policy, and interviews, it was determined the facility failed to ensure Certified Medication Aides (CMAs) performed tasks which they had the knowledge, skills, and competencies. This was true for 4 of 4 CMAs reviewed for medication administration competencies. This failure increased the risk for harm to residents receiving insulin when the CMAs did not have the appropriate medication administration competencies and skill sets to assure resident safety during insulin administration.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure a resident was free from a physical restraint. This was true for 1 of 1 resident (Resident #42) reviewed for physical restraints. This deficient practice placed Resident #42 at risk of experiencing loss of dignity, sleep disturbances, fear, agitation, and anxiety.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's comprehensive care plan was implemented. This was true for 1 of 12 residents (Resident #11) whose care plans were reviewed. This failure placed Resident #11 at risk of negative outcomes when his care plan was not implemented for mobility transfers.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and revised to reflect current needs and interventions. This was true for 1 of 12 residents (Resident #9) whose care plans were reviewed. This failure created the potential for harm if care and services were not provided due to inaccurate or incomplete information in the care plan.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure maintenance of a resident's urinary needs were met. This was true for 1 of 1 resident (Resident #11) reviewed for bowel and bladder care. This failed practiceplaced Resident #11 at risk for deterioration in bowel and bladder function.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure nutritional assistance was provided to residents. This was true for 1 of 12 residents (Resident #11) reviewed for nutritional assistance. This deficiency placed Resident #11 at risk for undetected weight loss and nutritional deficits.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 1 resident (Resident #9) whose record was reviewed for respiratory services. This failure created the potential for Resident #9 to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were dated when opened and not expired, and residents' medications were labeled with the resident's identifying information. This was true for 1 of 2 medication carts inspected. This failure created the potential for residents to receive the wrong medication or expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 45 of 46 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 12 residents (Resident #11) observed during peri care. This failure had the potential for adverse outcome due to risk for cross contamination and infection.