Three Meadows Post Acute

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to ensure medications were stored in a locked compartment. This had the potential to affect all residents residing on the first and second floors, except 13 (#250, #251, #252, #253, #254, #255, #256, #257, #258, #259, #260, #261, and #262) residents identified by the facility as residing on the secured memory care unit. The facility census was 91.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure protected health information (PHI) remained secure. This affected one (#155) of one resident observed for PHI. The facility census was 91.

Inspectors wroteBased on medical record review, observations, staff interviews, and review of facility policies, the facility failed to utilize enhanced barrier precautions (EBP) and perform hand hygiene to prevent the spread of infection. This affected two (#165 and #185) of two residents observed for the use of EBP. The facility census was 91.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to ensure residents with identified hearing concerns were seen timely by the audiologist. This affected one resident (#82) of three residents reviewed for ancillary services. The facility census was 101. Findings Include:Review of Resident #82's medical record revealed an admission date of 10/24/24. Diagnoses included endometrium cancer, chronic obstructive pulmonary disease, lymphedema, anxiety disorder, osteoarthritis, depression, and unspecified hearing loss. Review of Resident #82's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #82 was cognitively intact. Resident #82 had moderate difficulty hearing. Resident #82 was on hospice at the time of the review. [...]

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure post fall follow up assessments were completed and care planned fall interventions were implemented. This affected one resident (#52) out of three residents reviewed for falls. The facility census was 101. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included neuroleptic induced Parkinsonism, hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side, bipolar disorder, anxiety disorder, repeated falls, adrenocortical insufficiency, chronic kidney disease stage 3B. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure physicians orders were followed for oxygen therapy and the use of a Continuous Positive Airway Pressure (CPAP). This affected one (#94) of three residents reviewed for assistive breathing devices. The census was 101. Findings Included:Review of the medical record for Resident #94 revealed an admission date of 02/17/22. Diagnoses included acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/25, revealed the resident had intact cognition. The resident was dependent on staff for Activities of Daily Living (ADL) and eating. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure medication was available as prescribed. This affected one (#94) of two residents reviewed for medication administration. The facility census was 101. Findings Included:Review of the medical record for Resident #94 revealed an admission date of 02/17/22. Diagnoses included acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for Activities of Daily Living (ADLs) and eating. [...]

Inspectors wroteBased on observation, medical record review, review of wound care provider documentation, review of hospital documentation, staff interview, family interview, nurse practitioner interview, review of the National Pressure Injury Advisory Panel 2025 guidelines, and review of facility policies, the facility failed to provide a timely assessment, ongoing monitoring, and interventions to prevent the development of a pressure ulcer for Resident #05, who was known to have arterial and venous insufficiency, and who was identified at risk for pressure ulcers. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcome on 09/07/25 when Resident #05 was found with an unstageable pressure ulcer to the right malleolus (ankle) underneath an ankle monitoring device. [...]

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure resident representatives and physicians were notified of changes in condition. This affected one (#05) of three residents reviewed for changes in condition. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. [...]

Inspectors wroteBased on observation, review of the medical record, resident interview, staff interview, and policy review. The facility failed to ensure surgical wound care was completed per physician orders. This affected one resident (#43) of three residents reviewed for wound care. The facility identified five residents with surgical wounds. The facility census was 83. Review of the medical record for Resident #43 revealed an admission date of 09/10/25 and a readmission date of 10/23/25. Diagnoses included pneumonia, anxiety, and surgical aftercare following surgery of the digestive system. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 11/18/25 revealed the resident had a surgical wound to the right upper quadrant mid abdomen. [...]

Inspectors wroteBased on review of the medical record, review of bowel records, staff interview, and policy review, the facility failed to ensure bowel movements were accurately documented and failed to ensure the bowel protocol was followed when a resident was without a bowel movement for greater than three days. Additionally, the facility failed to timely complete a bowel assessment for a resident with a known history of constipation who had no documented bowel movements for six days. This affected one (#74) of three residents reviewed for bowel and bladder. The facility census was 83. Review of the medical record for Resident #74 revealed an admission date of 02/17/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, type two diabetes mellitus, chronic kidney disease, and osteoarthritis. [...]

Inspectors wroteBased on observation, review of the medical record, staff interview, resident interview, family interview, and policy review revealed the facility failed to ensure medical documentation was complete and accurate. This affected two (#5, #51) of three residents reviewed for clinical documentation and had the potential to affect all residents. The facility census was 83. 1. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. [...]

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions were maintained during wound care. This affected one (#05) of four residents reviewed for wound care. The facility identified 29 residents with enhanced barrier precautions. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. [...]

Inspectors wroteBased on observation, medical record review, review of wound center documentation, staff interview, and review of a facility clinical protocol, the facility failed to provide timely assessment, monitoring, and interventions to prevent the development of a pressure ulcer. Actual harm occurred when Resident #56, who was assessed at moderate risk for pressure ulcer development, had care plan interventions for skin checks each shift with no documented evidence of the skin checks completed. Subsequently, the resident was discovered with a unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left lateral heel and no ongoing assessments were completed to determine causative factors of the wound development or need to change pressure reduction interventions. Resident #56's wound required surgical debridement and ongoing treatment applications as a result. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure call lights were within reach for one (#43) of four residents reviewed for call light accessibility. The census was 81.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to maintain a clean environment. This affected two (6 and #49) of four residents reviewed for physical environment. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#24) of five residents reviewed for psychotropic medications. The facility census was 81.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide ongoing assistance and coordination, with resident involvement, in developing discharge goals and plans for discharge. This affected one (#62) of one residents reviewed for discharges in a facility census of 81.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to provide adequate staff assistance and implement fall interventions during care to prevent falls. This affected one (#19) of two residents reviewed for falls. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, and review of the dialysis contract, the facility failed to ensure effective communication took place between the facility and the dialysis center. This affected one (#34) of one residents reviewed for dialysis. The facility census was 81.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were provided as ordered by the physician and within prescribed time frames. This resulted in 12 of 28 medications being administered in error with an error rate of 42.86 percent (%). This affected three (#53, #16, and #74) of four residents observed for medication administration in a facility census of 81.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were administered as ordered, and within ordered time frames, to prevent significant medication errors. This affected three (#53, #16, #74) of four residents observed for the administration of medications in a facility census of 81.

Inspectors wroteBased on observation, staff interview, and review of the diet manual guidance, the facility failed to ensure pureed food items had an appropriate texture. This had the potential to affect two (#51 and #231) of two residents on a pureed diet. The facility census was 81.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident meal trays were served in a sanitary manner. This affected one (#62) of seven residents observed during dining services. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to properly store medications. This affected one resident (#78) reviewed for medications left at bedside. The facility census was 81.

Inspectors wroteBased on medical record review, staff and hospice staff interviews, review of medication information from Medscape and facility medication administration policy, the facility failed to ensure blood pressure medication was administered in accordance with physician orders. This resulted in a significant medication error when one resident received an anti-hypertensive blood pressure medication outside of physician prescribed administration parameters. This affected one (#1) of five sampled residents reviewed for the administration of medications. The facility census of 85.

Inspectors wroteBased on observation, staff and resident interview, review of the medical record, and review of a facility policy, the facility failed to ensure a resident was safely transferred using a mechanical lift per the care plan and facility policy. This affected one (#48) of one residents observed for a mechanical lift transfer. The facility census was 79.

Inspectors wroteBased on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79.

Inspectors wroteBased on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure the facility was adequately staffed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to notify the physician of medication being unavailable from the pharmacy for administration. This affected one (Resident #76) of three reviewed for medications. The facility census was 70.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders. This affected one Resident (#76) of three residents reviewed for medications. The facility census was 70.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure an admission skin assessment was completed, and failed to ensure wound treatments were entered into the electronic medical record and completed per physician orders. This affected one (Resident #79) of three residents reviewed for pressure ulcers. The facility census was 78.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the menu was reviewed by the facility's dietitian. The had the potential to affect all residents who received food from the kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #41, Resident #50, and Resident #189). The facility census was 85.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure the dishwashing machine was hot enough to sanitize the dishes. The had the potential to affect all residents who received food from the kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #41, Resident #50, and Resident #189). The facility census was 85.

Inspectors wroteBased on medical record review, resident and staff interview, review of pharmacy receipts and review of facility policies, the facility failed to ensure medications were administered per physician order. This affected four (#13, #63, #133, and #193) of 23 residents reviewed for medication administration. The facility census was 85.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure call lights were within reach of residents. This affected two (#184 and #188) of two residents reviewed for call lights. The facility census was 85.

Inspectors wroteBased on record review, resident interview, staff interview, review of activity participation records, observation, and review of activity schedules, the facility failed to ensure residents choices were honored to be out of bed when desired and to attend activities of choice. This affected one (Resident #36) of two residents reviewed for choices. The facility census was 85.

Inspectors wroteBased on resident interview, staff interview, review of facility records and review of the facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#7) of four residents reviewed for resident trust accounts. The facility census was 85.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a code status was accurately portrayed in the resident's medical record. This affected one (Resident #2) of 28 residents reviewed. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to notify the physician when ordered medications were unavailable. This affected one (#193) of one resident reviewed for notification of change. The facility census was 85.

Inspectors wroteBased on medical record review, review of the resident census, resident interview, staff interview and review of the facility admission packet, the facility failed to provide written bed hold notification to a resident upon transfer to the hospital. This affected one (#61) of two residents reviewed for hospitalization. The facility census was 85.

Inspectors wroteBased on medical record review, observation, resident and staff interview, the facility failed to ensure residents that required assistance with shaving were provided adequate care and services and further the facility failed to provide personal hygiene for a resident with dry skin. This affected two residents (#55 and #56) of six residents reviewed for activities of daily living. The census was 85.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure splint devices were applied as ordered by the physician. This affected one (#56) of one residents reviewed for range of motion. The facility identified Resident #56 as the only resident in the facility with orders for a splint. The census was 85.

Inspectors wroteBased on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure medications were administered as ordered. This resulted in three medication errors of 28 total opportunities for a medication error rate of 10.71%. This affected one (#133) of three residents observed during medication administration. The census was 85.

Inspectors wroteBased on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure insulin was administered as ordered. This affected one (#133) of three residents observed during medication administration and one (#193) of one residents reviewed for insulin usage. The facility identified 25 residents in the facility with orders for insulin. The census was 85.

Inspectors wroteBased on observation, staff interview, medical record review, and review of drug manufacturer's instructions, the facility failed to ensure insulin was stored in a safe manner. This affected two (#28 and #40) of eight residents who had insulin stored in the North One, South Two, and Subacute Two medication carts. The facility identified 25 residents in the facility with orders for insulin. The census was 85.

Inspectors wroteBased on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure pureed foods were prepared in a manner to maintain the nutritive value and ensure proper portion size. This had the potential to affect two residents (#18 and #68) who were identified on a pureed diet. The facility census was 85.

Inspectors wroteBased on staff interview, record review, review of the pharmacy recommendations, and review of the facility policy, the facility failed to follow up on pharmacy recommendations regarding the use of prophylactic antibiotics and physician recommendations for infectious disease consult. This affected one resident (#19) of three reviewed for prophylactic antibiotics. The facility census was 85.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure resident call systems in the bathroom were maintained in working order. This affected one (#15) of 23 sampled resident's bathrooms observed for functioning call lights. The census was 85.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure a clean environment. This affected one (#26) of seven residents reviewed for environment. The facility census was 85.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide a bed hold notification to the resident, and or the resident's representative. This affected three Residents (#11, #45, #56) of four reviewed for hospitalization. The facility census was 114.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure safe and effective medication administration assistance when medications were left at the bedside for one Resident (#68) of one observed for medications unattended. The facility further failed to appropriately store medications safely. This had the potential to effect 15 residents (#53, #52, #89, #24, #4, #68, #22, #66, #13, #36, #02, #12, #15, #63, and #70) who the facility identified as cognitively impaired and independently mobile on the second floor. The facility census was 114.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to cover food during transportation and distribution to residents. This had the potential to affect all 100 residents who received trays off the hall carts. Resident #93, #19, #4, #31, #42, #23, #68, #106, #29, #13, #33, and #46 received food in the main dining room and Resident #61 and #82 received no food by mouth. The facility census was 114.

Inspectors wroteBased on observation and staff interview, the facility failed to serve residents lunch at the same time who were sitting at the same table together. This affected one Resident (#36) of four observed during the lunch meal. The facility census was 114.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to implement their abuse policy to report and investigate when a resident reported her cell phone was missing. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to report an allegation of missing property. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to fully investigate an allegation of missing property. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to offer quarterly care plan conferences for one Resident (#74) of one reviewed for care conferences. The facility census was 114.

Inspectors wroteBased on medical record review, observation, family interview, staff interview, and review of facility nursing procedure, the facility failed to ensure a dependent resident was provided with activities of daily living (ADLs). This affected one Resident (#82) of six reviewed for ADLs. The census was 114.

Inspectors wroteBased on medical record review, staff and resident interviews, and facility policy review, the facility failed to complete treatments as ordered and failed to complete a minimum of weekly non-pressure and pressure wound assessments for two Residents (#57 and #69) of five reviewed for pressure ulcers. The facility census was 114.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure a resident with a colostomy received care and treatments as ordered. This affected one Resident (#8) of one reviewed for colostomy care. The facility census was 114.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility pain flow sheet, the facility failed to ensure a resident's pain medications was administered in a timely manner. This affected one Resident (#50) of one reviewed for pain management. The facility census was 114.

Inspectors wroteBased on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents who received hemodialysis had their fistulas monitored as ordered. This affected one Resident (#8) of one reviewed for dialysis. The facility census was 114.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to administer multiple doses of intravenous (IV) antibiotics per the physician orders for one resident (#57) of one reviewed for infections. The facility census was 114.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure a medication was disposed of to prevent a potential infection control incident. This affected one Resident (#65) of two residents reviewed for medication administration. The census was 114.