Spring Meadows Health and Rehabilitation

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices for 1 of 2 (Resident #20) residents reviewed for isolation precaution. The facility had a census of 107.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide effective maintenance services to ensure a safe, functional, and comfortable environment as evidenced by the disrepair of the bathroom flooring for 1 out of 104 occupied resident's rooms.

Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete resident assessments, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process, within the regulatory time frames for 7 of 28 sampled residents (Resident #5, #17, #22, #48, #76, #86, and #93) reviewed for completion of the MDS resident assessments.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to ensure a care plan meeting was scheduled for 2 of 2 (Resident #8 and #23) reviewed for care plan meeting.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure followed practitioner orders for a Percutaneous Gastrostomy (PEG) tube feeding and failed to date and label PEG tube feedings for 1 of 2 (Resident #63) sampled residents reviewed for enteral feedings.

Inspectors wroteBased on review of staff in-services and interview the facility failed to ensure the mandatory annual 12 hours of in-services were provided for the Certified Nursing Assistant (CNA) for 12 of 61 staff members (CNA A, B, C, D, E, F, G, H, I, J, K, and L reviewed for in-servicing training.

Inspectors wroteBased on weather website review, policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for wandering and elopement. [...]

Inspectors wroteBased on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents (Resident #45, #87, #19, #68, and #90) reviewed for wandering/elopement behaviors and at risk for abuse. [...]

Inspectors wroteBased on weather website review, policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for elopement/wandering behaviors. Resident #45, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing North exit door on a cold January day, walked approximately 94.6 feet and was found by staff standing in the parking lot for an undetermined amount of time. [...]

Inspectors wroteBased on policy review, Board of Examiners for Nursing Home Administrators (BENHA) review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of cognitively impaired residents with wandering behaviors. Administration failed to provide oversight to monitor and provide a safe resident environment for cognitively impaired residents with wandering behaviors, to report, and investigate incidents of elopement. [...]

Inspectors wroteBased on policy review, job description review, Quality Assurance Performance Improvement (QAPI) reports, medical record review, observation, and interview, the QAPI committee failed to ensure systems and processes were in place that involved tracking/trending, evaluation/reevaluation of interventions, data, and trends to address quality concerns related to wandering and elopement behaviors. The QAPI committee failed to ensure a thorough investigation of a resident elopement, failed to identify quality deficiencies and effective interventions, failed to monitor the effectiveness of the interventions, and failed to assess staff knowledge of the care of residents with wandering/elopement behaviors in order to identify deviations and adverse events when residents exited the facility without staff knowledge. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when the oven had build-up of a shiny, brown substance on the inside doors and all sides in the inside of the oven, the coffee machine had a build-up of black splashes and the spout of the coffee machine had a build-up of a dark gray substance, the toaster had a build-up of crumbs, the juice machine had a build-up of a thick, orange, red, and tan substance on the spout and on the sides of the machine, there was a pink, slimy substance on the water curtain of the ice machine in the Dining Room, the stove's grease trap was filled with a black liquid with thick black stringy material and a thermometer floating in it, the stove's drip pan had several particles of dried food and dark grime covering the pan, there was a build-up of a black substance [...]

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, agency invoices, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 23 of 121 staff members (Dietary Aide #2, #3, and #4, Housekeeper #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #4 and #8, Agency LPN #1, #2, and #3, Certified Nursing Assistant (CNA) #4, #5, #6, and #7, and Agency CNA #1, #2, #3, #4, #5, #6, and #7) failed to complete screening for the prevention and detection of COVID-19 prior to working on 1 of 1 days (7/15/2022) reviewed. This had the potential to affect the 109 residents residing in the facility.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advance Directive to residents or the residents' responsible parties for 21 of 24 sampled residents (Resident #2, #3, #9, #12, #14, #15, #16, #19, #22, #28, #30, #34, #39, #45, #62, #67, #76, #82, #100, #153 and #255) reviewed for Advanced Directives.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 sampled residents (Resident #37) were free of a significant medication error when 1 of 5 licensed nurses (Licensed Practical Nurse (LPN) #4) administered an incorrect dosage of an anticoagulant medication.

Inspectors wroteBased on facility policy review, Registered Dietician contract review, record review, observation, and interview, the facility failed to maintain proper kitchen sanitation when 2 of 6 Kitchen staff (Dietary Aide #2 and #3) had unrestrained facial hair, food was open to air in the freezer, and 2 of 3 Kitchen staff (Cook #1 and Dietary Aide #1) did not record the correct 3 compartment sink sanitizer results. This had a potential to affect 85 of the 89 residents receiving meals from the Kitchen.

Inspectors wroteBased on policy review, record review, observation, and interview, the facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services for 3 of 3 (Cook #1, Dietary Aide #1, and Dietary Manager) Kitchen staff observed performing sanitizer testing. This had a potential to affect 85 of the 89 residents receiving meals from the kitchen.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop a comprehensive Care Plan to reflect the resident's current status for antidepressant, anticoagulant, and antianxiety medication use for 2 of 21 sampled residents (Resident #21 and #28) reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to document assessments and follow physician's orders for 1 of 2 sampled residents (Resident #77) reviewed with pressure injuries.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's order for oxygen therapy for 1 of 1 sampled residents (Resident #83) reviewed for oxygen.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when 2 of 2 nurses (Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1) failed to perform proper hand hygiene for 2 of 4 sampled residents (Resident #77 and Resident #189) observed during wound care and isolation, and when 1 of 1 nurses (LPN #2) failed to properly dispose of a contaminated lancet for 1 of 1 sampled resident (Resident #86) observed during blood glucose monitoring.