Country Meadow Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Country Meadow Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 6, 2022

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, staff interviews, review of the facility witness statements, and review of the facility's policy for Cardio-Pulmonary Resuscitation (CPR), the facility failed to initiate CPR or contact Emergency Medical Services (EMS) for Resident #11 who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. This resulted in Immediate Jeopardy when Resident #11 did not receive CPR and EMS was not contacted for assistance. This affected one (Resident #11) of three residents reviewed for death in the facility. The facility identified 15 residents designated as having a Full Code status. The facility census was 37. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2026

  Based on observation and staff interview, the facility failed to maintain the kitchen in a clean, sanitary manner. This had the potential to affect all residents as the facility identified all residents received food from the kitchen. The facility census was 38. Findings include:During an observation of the kitchen on 07/27/26 from 8:10 A.M. to 8:25 A.M., the ceiling air-duct vents contained a heavy accumulation of dust and debris. The affected vents were located near the kitchen food-preparation and serving areas. No exposed food was positioned directly beneath the vents during the observation.During a dietary-service observation on 07/28/26 from 11:30 A.M. […]

• No harm, potential for more than minimal, widespreadF887Jul 30, 2026

  Based on record review and interview the facility failed to maintain a staff SAR-Cov-02 (COVID-19) vaccine log. This had the potential to affect all residents residing in the facility. The facility census was 38.Findings Include:Review of the facility's staff COVID-19 vaccine logs revealed the last update to the logs were completed in 2023-2024 and had been completed by the previous administrator.Interview on 07/29/26 at 2:50 P.M. with the Assistant Director of Nursing (ADON) verified the facility does not have an updated staff COVID-19 vaccine log. The ADON stated the previous administrator and human resources had been updating the logs.

• No harm, potential for more than minimal, widespreadF565May 30, 2024

  Based on record review and interview, the facility failed to provide the resident council with responses and action regarding their concerns regarding activities. This affected five residents (Resident #3, #5, #20, #27 and #36) who regularly attend council meetings and had the potential to affect all residents. The facility census was 38. Findings include: Review of the facility resident council meeting minutes from 11/22/23 to 05/14/24 revealed the residents had voiced the following concerns related to activities during resident council meetings: a. At the resident council meeting held 11/22/23 , residents voiced concerns regarding knowing when activities are held, and where activity calendars were placed in their rooms. […]

• No harm, potential for more than minimal, widespreadF679May 30, 2024

  Based on observation, record review, interview and policy review, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the resident preferences and failed to ensure activities were scheduled on evenings and weekends. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of the Activity Participation Logs for March 2024, April 2024, and May 2024 revealed all residents had their own log for each month, on which residents' activity participation was logged. Residents were recorded as participating in activities, based on the date, and participation was logged as active, passive, or refusal to participate. […]