Allisonville Meadows

In the surveyor’s words

From the most serious findings on record at Allisonville Meadows, in the surveyor’s own words.

• Actual harm, isolatedF580Mar 25, 2025

  Based on interview and record review, the facility failed to ensure facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2) notified the nurse on duty of a resident experiencing a fall (Resident D) and timely notify the resident's physician of a fall with injury, resulting in Resident D experiencing moderately strong pain and a delay in the treatment of a left humerus fracture, for 1 of 2 residents reviewed for falls, and to timely inform a physician of a significant change in a lab value for 1 of 2 residents reviewed for hospitalization (Resident B). This deficient practice was corrected on 2/19/25, prior to the start of the survey, and was therefore past noncompliance. […]

• Actual harm, isolatedF684Mar 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident (Resident D) who had fallen the night of 1/21/25, was assessed by a licensed nurse and the licensed nurse was made aware of the fall incident by the facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2), who had assisted the resident back to bed, and ensure the resident had continued monitoring afterwards. The resident experienced moderately strong pain, had skin impairments, and was later hospitalized and identified with a fractured humerus at the hospital for 1 of 3 residents reviewed for falls. This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. […]

• Actual harm, isolatedF760Jan 3, 2025

  Based on interview and record review, the facility failed to administer a synthetic opioid pain patch in accordance with the physician order, the manufacturer's specifications, or accepted professional standards to prevent a significant medication error for 1 of 3 residents reviewed for medication regimen. (Resident C) This deficient practice resulted in the resident having two opioid pain patches applied simultaneously, the resident experienced a significant change in consciousness that required emergent administration of an opioid overdose medication, and hospitalization . This deficient practice was corrected on 12/31/24, prior to the start of the survey, and was therefore past noncompliance. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2022

  Based on observation and interview, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for 123 of 125 residents that reside at the facility. Findings include: A kitchen tour with RD (Registered Dietician) was conducted on 11/29/22 at 10:55 a.m. During the kitchen tour, the following was observed: - 3 large, plastic cereal containers identified as Rice Krispies, Frosted Flakes, and Cheerios, had stickers on them which indicated they were prepped on 10/10 and a use by date of 11/10. - 6 pre-made bowls of cereal identified as Shredded Wheat were on a multi-shelf unit with lids. […]

• No harm, potential for more than minimal, patternF550Apr 15, 2026

  Based on interview and record review, the facility failed to ensure the dignity of residents was maintained and respected for 3 of 4 resident reviewed for dignity and 16 of 134 residents reviewed in resident council. (Residents' B, E, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z).Findings include: 1. The clinical record for Resident B was reviewed on 4/9/25 at 3:27 p.m. The resident's diagnoses included, but were not limited to, dementia (progressive decline in cognitive function) and deafness. A care plan, initiated 1/29/26, indicated Resident B required assistance with Activities of Daily Living (ADL) care including bed mobility, transfers, eating, and toileting. […]