Royal Meadow View Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided care and treatment in accordance with acceptable standards of practice, when on 04/07/26, Nurse #1 provided a Bisacodyl (laxative) suppository to Certified Nurse Aide (CNA) #1 to administer rectally to Resident #1, which was not within a CNA's scope of practice or job description and per the facility, was not a procedure that CNAs could perform.

Inspectors wroteBased on observations, record review and interview, the facility failed to identify and assess the use of pillows and a blanket tucked under a fitted sheet on both sides of the bed, as well as the use of a geri-chair (a reclining chair) directly next to the bed as a potential restraint for one Resident #74 out of a total sample of 20 Residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with pressure ulcers necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two Residents (#7 and #26) out of total sample of 21 residents. Specifically: 1.) For Resident #7, the facility failed to implement treatment recommendations by the consultant Wound Physician for a.) a Stage IV pressure wound of the left ischium and b.) an unstageable pressure injury of the lower sacrum. 2.) For Resident #26, the facility failed to implement treatment recommendations by the consultant Wound Physician for a stage IV pressure ulcer of the sacrum.

Inspectors wroteBased on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated food, that staff did not store personal drinks with resident food and ingredients, and that staff did not serve undercooked unpasteurized eggs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, 1a.) For Resident #76, the facility failed to implement enhanced barrier precautions. 1b.) For Resident #24, the facility failed to implement enhanced barrier precautions. 2.) For Resident #26, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care. 3.) The facility failed to sanitize shared resident equipment between resident uses.

Inspectors wroteBased on observation and interview, the facility failed to provide a dignified dining experience for residents residing on the dementia unit.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement person-centered care plans for one Resident (#28) out of a sample of 21 residents. Specifically, for Resident #28, the facility failed to implement the plan of care for providing supervision/assistance and adaptive equipment to the Resident while eating.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#26) out of a total sample of 21 residents. Specifically, the facility failed to revise the comprehensive care plan relating to tube feeding and risk for choking upon the care plan review following the completion of two quarterly assessments.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure services provided met professional standards of quality for one Resident (#7) out of a total of 21 sampled residents. Specifically, the facility failed to implement wound treatments initiated by the consultant Wound Physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one dependent Resident (#55) out of a total sample of 21 residents. Specifically, for Resident #55, the facility failed to: 1a.) Provide set-up assistance and supervision with meals. 1b.) Provide assistance with nail care. Findings Include: Review of the facility policy titled 'Activities of Daily Living (ADLs)', undated, indicated, but was not limited to, the following: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#76) out of a total sample of 21 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag and tubing was not placed directly on the floor.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for one Resident (#55) out of a total sample of 21 residents. Specifically, the facility failed to assess Resident #55 for risk of entrapment from bed rails prior to installation.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure residents were free of unnecessary medications and were properly assessed for possible adverse reactions to psychotropic medications for two residents (#47 and #22) out of a total of 21 sampled residents. Specifically: 1.) For Resident #47, the facility failed to ensure the use of as needed (PRN) psychotropic medications were limited to 14 days for one Resident (#47). 2). For Resident #22, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in one out of three medication carts observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accurate medical records for two Residents (#26 and #22), out of a total sample of 21 residents. Specifically: 1.) For Resident #26, the physician and nurse practitioner inaccurately documented the Resident's code status as do not resuscitate (DNR) when the Resident's code status indicated to attempt resuscitation (full code). 2.) For Resident #22, the facility inaccurately documented the Resident's physician's order as a full code (attempt resuscitation) when the Resident's Medical Orders about Life-sustaining Treatment (MOLST) indicated the Resident was DNR, do not intubate (DNI).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive, without a pulse, without respirations, and although his/her advanced directives indicated he/she was a Full Code (in the event of cardiac or respiratory arrest, attempts at resuscitation will be initiated) the Facility failed to ensure nursing staff adequately assessed Resident #1 for signs of irreversible death and followed facility policy, before initiating and attempting to perform cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose advanced directive indicated he/she was Full Code, (staff to attempt Cardiopulmonary Resuscitation, CPR in the event of cardiac or respiratory arrest) the Facility failed to ensure that nursing staff were competent related to facility policy and procedures in the event of an emergency situation with the need to initiate a Code Blue, which included nursing response, resident assessment and use of necessary life-saving equipment. When on [DATE], at approximately 7:00 A.M., after Nurse #1 found Resident #1 unresponsive, without a pulse or respirations, Nurse #1 did not stay with the resident, Code Blue was not overhead page to alert staff per Facility Policy, and nursing staff were unaware of how to use the Automated External Defibrillator (AED).

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that; 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For 2 Residents (#50 and #86) the facility failed to provide care when requested out of a total of 27 residents sampled.

Inspectors wroteBased on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of two units.

Inspectors wroteBased on interview and review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 2023, the facility staff failed to ensure an effective QAPI plan was in place.

Inspectors wroteBased on observations, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to 1) ensure nursing staff performed hand hygiene appropriately during medication administration and follow recommended disinfectant guidelines and 2) complete a risk management assessment for the possible development and spread of legionella.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident rooms were maintained in good repair, clean and homelike on 2 of 3 resident care units.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of two nurses observed made 4 errors out of 33 opportunities resulting in a medication error rate of 12.12 %. Those errors impacted two Residents (#23, and #28), out of 4 residents observed.

Inspectors wroteBased on interview and record review the facility failed to ensure that a system was developed to conduct comprehensive inspections of resident's mattresses in zone 7, to reduce the potential hazard of entrapment for beds in the facility. Specifically, the facility failed to identify a greater than 12 inch bed gap for one Resident (#67) and a 5.5 inch gap for one Resident (#72) out of a total sample of 27 residents.

Inspectors wroteBased on observation, policy review, and interview the facility failed to provide a dignified dining experience for 2 Residents (#80 and #85) out of a total sample of 27 Residents. Specifically, the facility failed to ensure that staff members were not standing over Residents #80 and #85 while providing feeding assistance.

Inspectors wroteBased on observations, record review, and interview, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for one Resident (#72), out of a total sample of 27 residents.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours of admission for one Resident (#90), who was at risk for elopement, out of a total sample of 27 residents.

Inspectors wroteBased on observations, record review, and interview, the facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for one Resident (#72), out of a total sample of 27 residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain professional standards of practice for medication administration for one Resident (#54) out of a total sample of 27 residents. Specifically, for Resident #54, who resides on the facility's Dementia Speciality Care Unit, the nurse failed to ensure Resident #54 had swallowed the medication that she administered.

Inspectors wroteBased on record review, observation and interview the facility failed to provide the necessary services to ensure 1 Resident (#85) out of a total sample of 27 residents, was able to effectively communicate his/her needs.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure supervision with meals was provided for one Resident (#44) out of a total sample of 27 residents.

Inspectors wroteBased on policy review, record review and interview the facility failed to maintain acceptable parameters of nutrition status for 1 Resident (#13) out of a total sample of 27 residents. Specifically, the facility failed to review or implement the Registered Dietitian's (RD's) recommendation for increasing the frequency of Resident #13's nutritional supplement. Findings Include: Review of the undated facility policy titled Weight Surveillance, indicated, but was not limited to, the following: -Significant weight change is considered if 5% or more gain or loss within one month, 7.5% or more gain or loss in three months, or 10% or more gain or loss in six months. -Dietitian to reassess and document interventions to address significant weight loss or gain. Resident #13 was admitted to the facility in August 2023 with diagnoses including dementia and adult failure to thrive. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#67 and #24) who had an active diagnosis of PTSD out of a total sample of 27 Residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate a food intolerance for 1 Resident (#19) out of a total sample of 27 Residents. Specifically, the facility failed to ensure that gluten-containing food was not served to a Resident with celiac disease (an auto-immune condition triggered by the consumption of gluten, a protein found in wheat, rye, barley, and triticale, which results in inflammation and damage to the lining of the small intestine).

Inspectors wroteBased on observation, policy review and interview the facility failed to handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that nursing staff did not touch resident food directly with their bare hands during set-up and feeding assistance in the dining room of the View unit.