Meyer Care Center

Inspectors wroteBased on interview and record review, the facility failed to complete and document an incident report, make notifications according to the facility protocol and investigate the fall/ injury when one sampled resident (Resident #2) had a fall from his/her bed that resulted in increased pain and possible injury out of three sampled residents. The facility census was 39 residents. Based on interview and record review, the facility failed to complete and document an incident report, make notifications according to the facility protocol and investigate the fall/ injury when one sampled resident (Resident #2) had a fall from his/her bed that resulted in increased pain and possible injury out of three sampled residents. The facility census was 39 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform one sampled resident (Resident #1) of transportation costs within the admission agreement out of seven sampled residents. The facility census was 53 residents. Review of the facility's policy titled Admissions dated from 2025 showed: -The facility would maintain an admissions policy governing admissions to the facility to ensure fair and impartial admission practices. -A nursing facility may charge a resident who was eligible for Medicaid for items and services the resident had requested and received only if: --That service was not defined in the State plan as nursing facility services (services required as part of the daily rate). --The facility informs the resident and the resident's representative in advance that the service was not covered to allow them to make an informed choice regarding the fee. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient proof of the Registered Nurse (RN) eight consecutive hours a day coverage during the Fiscal Year Quarter Two 2024 Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for all the dates triggered within the quarter equaling 26 total days. This deficient practice had the potential to affect all residents within the facility. The facility census was 53 residents. Review of the facility's undated policy titled Nursing Services- Registered Nurse showed: -The intent of the policy was for the facility to comply with Registered Nurse staffing requirements. -The facility would utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the baffle vents (metal vents which trap oil and grease that would make it into a kitchen's atmosphere by passing air through a series of interlocking baffles, because the oil gets stuck to the stainless steel or aluminum interior walls of the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air)) over the deep fat fryer free of a heavy buildup of grease; failed to maintain the floor behind the deep fat fryer free of a heavy buildup of grease; failed to maintain packages of zucchini sticks, breaded okra and frozen meat patties with a date and closed in the freezer; failed to maintain two cutting boards in an easily cleanable condition; [...]

Inspectors wroteBased on interview and record review, the facility failed to submit the required staffing data to the Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for two of the last four quarters which had the potential to affect all residents. The facility census was 53 residents. Review of the facility's undated policy titled Payroll Based Journal showed: -It is the policy of the facility to electronically submit timely to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data in uniform format according to specifications established by CMS. -The facility would submit direct care staffing information on the schedule specified by CMS, but no less than quarterly. -The reporting deadlines included: --Fiscal Quarter One (October 1- December 31): [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control practices during incontinence care for one sampled resident (Resident #20) who was on Enhanced Barrier Precaution (EBP - refer to an infection control intervention designed to reduce transmission of multi--resistant organisms that employs targeted gown and glove use during high contact resident care activities), who was at risk for infection due to an open wound on his/her coccyx (tail bone) area; failed to perform adequate hand hygiene during medication administration for one sampled resident (Resident #6) and two supplemental residents (Resident's #33 and #47) out of 15 sampled residents and nine supplemental residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Infection Control Surveillance process for monitoring and tracking the use of long-term antibiotic usage to be included in the monthly review and monitoring of the antibiotics for one sampled resident (Resident #17), who was on an antibiotic as a preventative measure for Chronic Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) out 15 sampled residents. This failure had the potential to affect all residents at the facility. The facility census was 53 residents. Review of the Facility's undated Infection Prevention and Control Program showed: -An Antibiotic Stewardship program will be implemented as part of the overall infection prevention and control program. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of in-service education (which was to include abuse, neglect, and dementia training) per year by not being able to produce documentation for five out of five CNAs employed with the facility for greater than 12 months reviewed and failed to monitor what education the CNAs had received. This had the potential to affect all residents within the facility. The facility census was 53 residents. Review of the facility's undated policy titled Continuing Education showed: -All levels of employees were expected to complete required trainings within the designated time frames. -It was the responsibility of each employee to complete the required training. -For training that was assigned as self-paced, the employee was responsible for completing the training by the deadline. [...]

Inspectors wroteBased on interview and record review, the facility failed to prepare and deliver quarterly statements to the Public Administrator (a guardian usually appointed or elected, who is responsible for the management of each ward's life, including where they reside, needed medical attention, and other decisions pertaining to personal well-being) who was the guardian for four sampled residents (Residents #14, #12, #15 and #22) who had resident funds at the facility. The facility census was 53 residents. 1. Review of the resident trust records for Residents #14, #12, #15 and #22, showed the absence of quarterly statements which were supposed to be prepared and delivered to their Public Administrator. During an interview on 7/17/24 at 12:50 P.M. the Business Office Manager (BOM) said: -He/She was hired as the BOM in April 2023. -He/She was not trained in preparing and sending quarterly statements. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking Nurse Aide Registry and completing criminal background checks (CBC) within a timely manner and in accordance with state requirements prior to employing four of 10 employees sampled for the criminal background screening. The facility census was 53 residents. Review of the facility's Abuse and Neglect policy and procedure dated 2023, showed: -The facility, to provide these protections (protecting the health, welfare and rights of each resident in the facility), the facility must develop written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications to residents with a medication error rate of less than 5%. Facility staff made five medication errors out of 27 attempts, for a medication error rate of 18.52%. This affected five out of ten residents observed during medication pass (Resident #156, #157, #6, #33, #47). The facility census was 53 residents. Review of an undated facility policy titled Medication Administration showed medications in accordance with professional standards of practice. Review of an undated facility policy titled Medication Errors showed: -The facility should have ensured medications were given per physician orders, according to manufacturers specifications regarding the preparation and administration of the drug, and in accordance with professional standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs were not bland; and failed to ensure that hot foods on room trays were at or close to 120 ºF (degrees Fahrenheit) at the time of delivery. This practice potentially affected one resident with a pureed diet and three residents who received room trays. The facility census was 53 residents. 1. Review of the recipe for five serving of pureed eggs, copyrighted 2024, showed: -Five boiled eggs and ¼ cup of warm milk. -Directions included: Place prepared eggs and milk in a washed and sanitized food processor, blend until smooth. Reheat to 165 ºF for at least 15 seconds and maintain at 135 ºF. Observation on 7/17/24 from 7:01 A.M. through 7:04 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to invite one sampled resident (Resident #22) to his/her quarterly care plan meeting out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Comprehensive Care Plans showed: -The comprehensive care plan would be prepared by an interdisciplinary that included the resident and the resident's representative, to the extent possible. -No policy related to the actual invitation to care plan meetings. 1. Review of Resident #22's face sheet showed he/she admitted to the facility with the following diagnoses: -Generalized Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Congestive Heart Failure (CHF- a weakness of the heart that leads to the build-up of fluid in the lungs and surrounding tissues). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the baseline care plan showed the primary health conditions and interventions implemented for two sampled residents with significant health conditions (Resident #154 and #155) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Baseline Care Plan dated 2023 showed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet the professional standards of quality of care. The baseline care plan will: -Be developed within 48 hours of the resident's admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - an air mattress covered with tiny holes that are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) settings were set by weight according to physician orders for one sampled resident (Resident #20), who had pressure ulcers (pressure injuries - damage to an area of the skin caused by constant pressure on the area) out of 15 sampled residents. The facility census was 53 residents. Review of the facility policy for Use of Support Surfaces copyright 2023 showed: -Support surfaces will be used in accordance with evidence-based practices for resident with or at risk for pressure injuries. -For powered devises, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and inflation. [...]

Inspectors wroteBased on observation, interview and record review, the failed to ensure respiratory nasal cannulas (a device used to deliver supplemental oxygen through a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), face masks and tubing was kept in a way to prevent cross contamination and failed to ensure that his/her care plan reflected that he/she used respiratory equipment and that there were interventions related to oxygen use for one sampled resident (Resident #36) out of 15 sampled residents. The facility census was 53 residents. 1. Review of Resident #36's Face Sheet showed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), and heart failure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess resident pain risk and failed to ensure the resident's Baseline Care Plan included minimum healthcare information regarding the specific care need of the resident to include pain for one sampled resident (Resident #155) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Pain policy and procedure dated 2023, showed: -The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of the resident's pain. -Based on professional standards of practice, an assessment of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information as applicable to the resident: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #22) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) received trauma based interventions or develop a care plan that showed interventions for the staff to provide to protect the resident and prevent trauma from recurring out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Comprehensive Care Plans showed: -Trauma-informed care was an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of traumas. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff had the proper skills and competencies to promote resident safety when a Certified Medication Technician (CMT) who was not certified to administer insulin (a drug used to manage blood sugar levels) injections administered insulin to two residents (Resident #156 and Resident #157) sampled for insulin administration. The facility census was 53 residents. Review of an undated facility policy titled Medication Administration showed medications were to be administered by staff who were legally authorized to administer those medications and in accordance with professional standards of practice. Review of an undated facility policy titled Insulin Pen showed staff were to: -Perform hand hygiene prior to the insulin administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's attending physicians documented their review of and response to irregularities identified by the facility's consulting pharmacist during monthly Medication Regimen Reviews (MRRs) for two residents (Resident #8 and Resident #32) of five residents reviewed for unnecessary medications. The facility census was 53. Review of an undated facility policy titled Psychotropic Medications showed effects of psychotropic medications on a resident's well-being would be monitored on an ongoing basis including during the pharmacist's monthly medication review but provided no other information on pharmacist medication reviews. A policy on pharmacist medication reviews was requested, but not provided prior to exit. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #6 and #1) received routine dental services (an annual inspection of the oral cavity for any signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic (a specialized branch of dentistry dedicated to making artificial teeth) care and procedures) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's undated policy titled Dental Services showed: -It was the policy of the facility to assist residents in obtaining routine and emergency dental care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to have monitoring and required documentation of Hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visits and failed to obtain pertinent documentation of the the delivery of Hospice care services for one sampled resident (for one sampled resident (Resident #35) out 15 sampled residents. The facility resident census of 53 residents. Review of the facility's Hospice Agreement dated and signed on 8/2/18 showed: -Hospice and the facility shall each establish and maintain it's own clinical record for each resident in Hospice program. -All services performed directly by the Hospice or under arrangement by the facility shall be promptly entered into respective clinic record. [...]

Inspectors wroteBased on observation and interview, the facility failed place a screen over the louvered vent in the basement boiler room to keep pests out of the boiler room area. This practice affected the boiler room area. The facility census was 53 residents. 1. Observation with the Maintenance Director on 7/16/24 at 9:45 A.M. showed the absence of a screen from the louvered vent in basement boiler room and the presence of dead insects, bird droppings and dried vegetation in the boiler room area. During an interview on 7/16/24 at 9:47 A.M., the Maintenance Director said birds have been in the boiler room in the past and he/she noticed there was no screen over the louvered vent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dishwasher spray wand nozzles free from debris inside the nozzles; to maintain the ceiling vents over the entrance to the kitchen free from a buildup of dust; to have a trash container available for Dietary [NAME] (DC) to use without having to touch the lid, which contributed to the DC not washing his/her hands after touching the trash container lid on multiple occasions; to ensure the shelf in the reach-in refrigerator labeled Pass Through, did not have visible rust on the shelf; and to ensure there was not a seven inch (in.) crack on the shelf of the food delivery cart. This practice potentially affected all residents who ate food from the kitchen. The facility census was 50 residents. 1. Observations on 9/26/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean mattress for one sampled resident (Resident #32); to maintain the fans in the beauty shop free of a heavy dust buildup; to maintain a fan in resident room [ROOM NUMBER] free of a dust buildup; to maintain the floors in resident rooms 301, 306, 308, 310, 312, 317, 316 and 321, free from debris buildup and dust; to maintain the commode seat in resident room [ROOM NUMBER] in an easily cleanable condition; to maintain commode risers (an extender to an existing toilet, under or over the lid, that lifts the seat height to a more comfortable level for residents who may be disabled) in resident rooms [ROOM NUMBERS]; to maintain a stand-up lift free from a crack in the base of that lift, and to clean debris from that lift. This practice potentially affected at least 20 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all employees were screened through the Nurse Aide Registry as part of the facility screening for Employee Disqualification and Criminal Background Check procedure upon hiring new employees for three of 10 sampled employee records. The facility census was 50 residents. Record review of the Facility's Abuse and Neglect policy and procedure dated May 2017, showed the facility would not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The community would not knowingly employ any direct care staff convicted of any of the crimes listed in the state criminal history of nurse aides or any other unlicensed employees or with a finding of abuse listed on the Nurse Aide Registry or criminal background check. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen review recommendations were reviewed and acted upon by the physician for three sampled residents (Resident #1, #5, and #15) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy Medication Regimen Reviews dated May 2019 showed: -The consulting pharmacist was to perform a Medication Regimen Review (MMR) for every resident in the facility receiving medication upon admission and at least monthly thereafter. -The pharmacist was to provide a written, signed, and dated copy of all medication regimen reports, including recommendations, to the Director of Nursing (DON) and Medical Director within 24 hours of the MMR. -The physician was required to document that the irregularity had been reviewed and what, if any, action was taken. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food items were labeled with a name and date when they were placed in to the resident food storage refrigerator, so the facility could follow the policy about discarding foods that needed to be discarded within 72 hours. This practice potentially affected two to three residents who had food items that were stored in that refrigerator. The facility census was 50 residents. Record review of the facility's policy entitled Foods brought by Family/Visitors revised 10/17, showed: -Food brought to the facility by visitors and family was permitted. Facility staff would strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Family members and visitors were requested to inform nursing staff of their desire to bring foods into the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices during blood glucose monitoring, including handwashing and glove changing and glucometer sanitation for one sampled resident (Resident #41) and one supplemental resident (Resident #16); failed to perform handwashing and glove changing before and after assisting a resident with a transfer for one supplemental sampled resident (Resident #18); and failed to perform hand hygiene upon entering a resident's room to perform blood pressure monitoring and before exiting the resident's room for one sampled resident (Resident #146) out of 13 sampled residents and four supplemental residents. The facility census of 50 residents. Record review of facility Blood Glucose Monitoring Policy and Procedure, dated 06/28/2017, showed: -Routine Procedure for Performing Finger Stick Blood Glucose. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Residents #1, #9 and #27), whose funds were managed by facility personnel, and to place the resident funds for two sampled residents (Residents #1 and #9) in an interest bearing account, since the total of their accounts exceeded $50.00. This practice affected all three residents whose resident funds were managed by facility personnel. The facility census was 50 residents. 1. Record review of Resident #1's guardianship paperwork, showed he/she was originally appointed a guardian on 10/22/08 and then appointed a successor guardian on 12/31/20, and the absence of an authorization form signed by the public administrator. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted timely for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy titled Resident Assessments dated November 2019 showed comprehensive MDS assessment was to be conducted no less than once every 12 months. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: -A Comprehensive Significant Change MDS assessment with an Assessment Reference Date (ARD) of 4/30/21. -A Quarterly MDS assessment with an ARD of 7/6/21. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' Minimum Data Sets (MDS-a federally mandated assessment instrument completed by facility staff for care planning) were submitted quarterly (at least every 92 days) for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the facility's policy titled Resident Assessments dated November 2019 showed: -A Quarterly MDS assessment was to be conducted no less than once every 3 months. -NOTE: The facility's policy did not address the time frame for submission. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit required Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) assessments within the regulatory time frame for one sampled resident (Resident #1) out of 13 sampled residents. The facility census was 50 residents. Record review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17 showed all MDS assessments must be submitted within 14 days of the Assessment Reference Date (ARD). 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid Services (CMS) MDS database submissions showed: -A Quarterly MDS assessment with an ARD of 7/6/21 was submitted 8/16/21, 41 days after the ARD date. [...]

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive care plan for a Continuous Positive Airway Pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) for one sampled resident (Resident #42) out 13 sampled residents. The facility census was 50 residents. Record review of the facility policy and procedure Care Plans-Service Plans dated 8/5/15 showed: -A preliminary Care Plan/Service Plan shall be developed upon the resident's admission to the community to meet his/her immediate care needs based on the initial nursing admission assessment. The preliminary Care Plan/Service Plan shall be used only until the comprehensive Care Plan/Service Plan has been developed. -The comprehensive Care Plan/Service Plan is developed within 14 days of the resident's admission unless state regulations state differently. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's order included the type of catheters (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine) the resident used to self-catheterize, how the facility would monitor urine output from the resident's self-catheterization and check for signs and symptoms of infection; to adequately assess the resident's knowledge of the process for self-catheterization and hand hygiene through demonstration; to monitor and document urine output for one sampled resident (Resident #146); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for oxygen were obtained and documented on the Physician's Order Sheet (POS) timely and upon admission for one sampled resident (Resident #146); and to ensure a nasal cannula and Bilevel Positive Airway Pressure machine (Bipap a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) cannula and tubing were stored in a way to prevent cross contamination for one sampled resident (Resident #146) and one supplemental resident (Resident #145) out of 13 sampled residents and 5 supplemental residents. The facility census was 50 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 29 observed medication opportunities, two errors occurred during insulin (Insulin is a hormone that lowers the level of glucose (a type of sugar) in the blood) administration resulting in an error rate of 6.9% for two sampled residents (Resident # 16 and Resident #41). The facility census was 50 residents. Record review of the facility's Insulin Injection Policy dated 6/2017 showed no mention of proper procedure for using insulin pens. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to remove dead insect carcasses from the floor of the storage room located on the south side of the hallway where the kitchen was located and the hot water heater room in the basement. This practice affected two non-resident areas. The facility census was 50 residents. 1. Observation on 9/27/22 with the Maintenance Director and Maintenance Assistant A showed: -At 2:59 P.M., there were beetles and other various dead insects on the floor of the storage room. -At 3:24 P.M., there were numerous dead insects on the floor of the hot water heater room in the basement area. During an interview on 9/27/22 at 3:25 P.M., the Maintenance Director said he/she needed to work on getting the dead insects cleaned up.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assure that the nutritive value and safe consumption of food was not compromised by ensuring hot foods were prepared by reaching proper internal temperatures (poultry at 165 degrees Fahrenheit (F) and fish at 145 degrees F) and served at a safe and appetizing temperature (135 degrees F). This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations on 10/1/19 between 11:37 A.M. and 11:49 A.M. showed foods being taken out of the oven and placed on carts to be taken to the dining rooms for the lunch meal service. During an interview on 10/1/19 at 11:57 A.M. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to keep the kitchen floors clean to avoid foodborne illness; failed to maintain sanitary food preparation and serving utensils; and failed to take measures to prevent non-food particles from getting into foods. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations during the kitchen inspection on 10/1/19 between 8:56 A.M. and 12:03 P.M. showed the following: - There were two butter pods, plastic and paper debris, and a coffee-colored stain approximately 2 feet by 3 feet under the racks in the walk-in refrigerator; - There was paper debris under the racks of the walk-in freezer; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 49 with a licensed capacity for 56 residents. Record review on 10/2/19 at 9:45 A.M. of the facility's Emegency Preparedness manual entitled [NAME] Care Center Disaster Manual, obtained from the [NAME] Meadows nurse's station, showed an absence of a waterborne pathogen prevention program that included the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to check the State Certified Nurse Aide (CNA) Registry to determine if a newly hired individual had a Federal Indicator (shows abuse, neglect or misappropriation of property occurred while the individual was employed as a CNA in a Medicaid and/or Medicare federally certified facility, which prohibits the individual from working in a certified facility) prior to hiring, for seven out of seven sampled employees. The facility hired 72 employees since the last annual survey. The facility census was 49 residents. Record review of the facility's Background Check Procedure dated 6/10/19 showed: -Staff were to check the CNA Registry unit on Certified Nurses Assistants (CNAs) and Certified Medication Technicians (CMTs); and --The policy did not direct the staff to check the CNA Registry for all staff. 1. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe and sanitary environment in two areas by allowing ceiling tiles to become dampened to the point of having visible mold growth on them. This deficient practice affected numerous residents, visitors, and staff who resided in, passed through, used, or worked in those two areas. The facility census was 49 residents with a licensed capacity for 56 residents. 1. Observations during the facility room-by-room Life Safety Code inspections with the Maintenance Assistant on 10/2/19 between 12:07 P.M. and 12:45 P.M. showed the following: - There were eight 2 foot by 2 foot ceiling tiles in the northeast corner of the Countryside Lane dining room that had visible mold near the sections by the wall; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff document a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) measurements and description weekly; and failed to ensure the resident's physician visited and visually assessed the resident every 30 days after admission to the facility for one sampled resident (Resident #23) out of 13 sampled residents. The facility census was 49 residents. Record review of the facility's undated Pressure Ulcer Prevention and Management policy showed: -The Interdisciplinary Team (IDT) Risk Team Representative reviews all new pressure ulcers and monitors progress weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner and a rationale was provided for a Gradual Dose Reduction (GDR) recommendation when the physician declined to reduce an antipsychotic, (medication used to manage disordered thoughts, delusions (altered reality or beliefs despite evidence to the contrary) and/or hallucinations (perceptions of having sensed something that wasn't actually there) for one sampled resident (Resident #14) out of 13 sampled residents. The facility census was 49 residents. Record review of the facility's Drug Regimen Review (DRR) Policy, dated 6/10/19, showed: -A licensed Pharmacist will review the resident drug regimen including the resident chart at least monthly or more frequently depending on the resident condition. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to educate all staff as to the readily accessible whereabouts and complete contents of a single, written, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 49 residents with a licensed capacity of 56 residents. During an interview on 10/1/19 at 8:56 A.M., the Dietary Manager said that there was a policy for outside food brought in for residents by family or visitors and subsequently provided a copy. Record review on 10/1/19 at 12:47 P.M. [...]