Vivo Healthcare Meadows

Inspectors wroteBased on record review, resident representative and staff interviews, the facility failed to ensure resident's refunds were refunded within 30 days after discharge for 1 (Resident #1) of 1 sampled resident due a refund.

Inspectors wroteBased on interviews, records reviewed and facility policy the facility failed to properly exercise the rights of 3, (Resident #5, Resident #3 and Resident #4), of 3 residents with dementia that had designated representatives by disenrolling the residents from their Medicare Advantage coverage without proper authorization and documentation.

Inspectors wroteBased on observation, review of facility policy, resident and staff interviews the facility failed to make timely necessary repairs to maintain a safe, functional environment for residents, staff and the public.

Inspectors wroteBased on observation, review of facility policy and resident and staff interviews, the facility failed to maintain an effective pest control program to eradicate and contain common household pests.

Inspectors wroteBased on observation, record review, facility policy and procedure review, and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected the status for 2 (Resident #78 and Resident #105) of 32 residents reviewed for accuracy of assessments. The Findings Included: The Resident Assessment - RAI Policy provided by the facility with an October 2024 Revised date stated, This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS . The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual . [...]

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to update the care plan and implement physician ordered interventions to prevent the development of pressure ulcers for 1 (Resident #42) of 2 residents reviewed with limited mobility.

Inspectors wroteBased on observation, review of the clinical record, review of facility policy and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #11) of 5 residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, record review, review of facility's policy and procedure and staff interviews the facility failed to provide or obtain dental services to meet the needs of 1 (Resident #78) of 1 resident observed with multiple broken, carious teeth.

Inspectors wroteBased on record review and interview the facility failed to ensure that within 30 days of discharge, eviction or death, residents personal funds and a final accounting is provided to the individual or probate jurisdiction administering the estate for 1 (Resident #1) of 3 residents reviewed discharged mid month.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 resident reviewed who returned to facility from the hospital.

Inspectors wroteBased on observation, record review, staff and resident interviews, the facility failed to implement processes to ensure accurate assessment and supervision of residents who smoke tobacco products to protect each resident's individual's safety and the safety of other residents. The facility failed to comprehensively assess and implement adequate interventions to minimize falls for 1(Resident #71) of 1 resident reviewed for falls. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. [...]

Inspectors wroteBased on observation, record review and staff interview the facility Administration failed to utilize its resources effectively to ensure safe smoking practices, including assessment and supervision of residents who smoke tobacco products to protect residents from serious injury, impairment, or death. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. The smoking area was observed with an overfilled pole cigarette receptacle and the surrounding area littered with cigarette butts. The floor of a clearly marked nonsmoking area had scattered cigarette butts. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain the kitchen in a sanitary manner and in good repair by failing to store cloths used for wiping surfaces in red sanitizing pails, failing to repair the leaking 3-compartment sink sprayer, failing to change the ice machine water filter according to manufacturer's specifications, storing measuring scoop for thickener inside of the bin in contact with the thickener, kitchen staff eating lunch while working and touching kitchen equipment, failing to wash hands between eating lunch, changing trash can bag, and placing lunch plates in the plate warmer.

Inspectors wroteBased on observation, resident, and staff interviews, the facility failed to promote a positive, dignified dining experience by failure to serve meals with appropriate, and matching silverware.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to provide housekeeping and maintenance services to ensure a clean, sanitary and homelike environment in 2 (400 and 600) of 6 halls observed, failed to ensure the availability of bed and bath linen to meet the needs of the residents and failed to implement policies and procedures to prevent the loss of personal items for 2 (Resident #59 and #84) of 5 sampled residents.

Inspectors wroteBased on observation, review of facility policy and procedures, staff and resident interviews the facility failed to provide the necessary care and services to maintain personal hygiene for 3(Resident #33, #60 and #101) of 4 residents observed for activities of daily living (ADLs).

Inspectors wroteBased on observations, review of the clinical records, review of facility policies and procedures, and staff interviews, the facility the facility failed to implement meaningful resident centered activities to meet the interest and wellbeing of 8 (Resident #22, #33, #34, #47, #71, #74, #88 and #209) of 8 residents reviewed for activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility.

Inspectors wroteBased on observations, record review, staff interview and resident interviews, the facility failed to provide food that is palatable, attractive, and at an appropriate temperature for 3 (Resident #32, 48, and 59) of 3 residents reviewed for food at the facility.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for 2 (Resident #24, and #74) of 4 residents reviewed with mental illness. This failure prevented residents from further evaluation to determine whether the residents required special services exceeding those provided by the nursing facility.

Inspectors wroteBased on interview and record review the facility failed to notify the appropriate mental health authority of a significant change in status for 1 (Resident #34) of 3 residents with diagnosis of mental illness reviewed for appropriate care and services.

Inspectors wroteBased on observation, record review, review of policies and procedures, resident and staff interview, the facility failed to supervise and ensure adequate monitoring to meet the needs for of 1 (Resident #67) of 2 sampled residents requiring the use of oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to show evidence of alternatives to side rails were attempted and an entrapment assessment was completed prior to the use of side rails for 2 (Residents #10 and #85) of 28 residents reviewed for use of side rails.

Inspectors wroteBased on record review, and interview the facility failed to ensure a yearly performance evaluation for 3 (Staff F, Staff CC, Staff EE) of 5 sampled Certified Nursing Assistants (CNAs).

Inspectors wroteBased on observations, review of facility policies, review of the clinical record and resident and staff interviews, the facility failed to ensure residents individualized behavioral health needs were met and failed to identify the underlying causes of the resident's depression, anxiety and agitation to prevent distress for 1 (Resident #58) of 2 residents reviewed for mental health services.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to make the necessary timely repairs to maintain a functional, and comfortable environment in the laundry room.

Inspectors wroteBased on observations, staff interviews and review of facility policies the facility failed to maintain a clean, safe, and homelike environment for residents evidenced by nonfunctioning clocks in resident rooms, calls bells not being within resident's reach, insects in resident rooms and common areas, and dirty rooms for four days of observations.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 2 residents (#35 and #54) out of 2 residents with oxygen and pacemakers.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to develop a comprehensive plan of care to address the identified problem of edema (swelling) for 1 (Resident #41) of 1 residents reviewed for edema.

Inspectors wroteBased on observations, staff interviews, resident record review and review of facility policy the facility failed to provide necessary services to maintain good grooming for 2 (Residents #94 and #202) of 2 residents requiring assistance with activities of daily living. This has the potential to cause psychological harm to the resident.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to provide treatment and care in accordance with professional standards for suture removal for 1 (Resident #8) of 1 resident reviewed for suture removal.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the absence of accident hazards for 1 resident (Resident #35) out of 1 residents observed for accident hazards.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide oxygen therapy, in accordance with physician's orders for 1 resident (Resident #80) of 2 residents reviewed for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of side effects and complications.

Inspectors wroteBased on interview, and record review the facility failed to ensure two residents' (Resident #44, and #19) of 5 residents surveyed for unnecessary medications were free from significant medication errors.