Meadow Green Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, patternF600Mar 13, 2024

  Based on record reviews and interviews, the facility failed to protect seven Residents (#5, #100, #19 #108, #26, #62 and #90) from abuse and neglect by staff out of a total sample of 41 residents. Specifically, the facility failed to prevent abuse 1a) after one Resident (#5) alleged that Certified Nursing Assistant (CNA) #16 forced him/her to take a shower and sprayed water in his/her face, causing emotional distress and 2) by neglecting to complete incontinence care for Residents #100, #19, #108, #26, #62 and #90. […]

• Actual harm, isolatedF689Oct 15, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, when on 09/28/24 Certified Nurse Aide #1 transferred him/her without assistance from another staff member, and as a result Resident #1 sustained a fractured right ankle, which required surgical intervention to repair. Findings include: The Facility's Policy, titled Safe Lifting and Movement of Residents, dated 08/01/23, indicated resident safety, dignity, comfort, and medical condition would be incorporated into goals and decisions regarding the safe lifting and movement of residents. […]

• No harm, potential for more than minimal, widespreadF565Mar 13, 2024

  Based on record review and interview, the facility failed to file and resolve grievances brought to the Resident Council group for four months. Findings include: Review of the policy titled, Grievances, dated 8/1/23, indicated the following: -Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. […]

• No harm, potential for more than minimal, widespreadF761Mar 13, 2024

  Based on observations, policy review, and interviews the facility failed to 1.) ensure that medications were properly labeled after opening in three of three medication carts observed on three of three nursing units. 2.) ensure medication carts were locked when unattended on one of three nursing units. Findings include: Review of the facility policy titled Medication Labeling and Storage. dated [DATE], indicated the following: -The facility stores medications and biologicals in locked compartments. -Compartments containing medications, including carts, are locked when not in use. -The medication label includes, at a minimum: expiration date, when applicable. […]

• No harm, potential for more than minimal, widespreadF835Mar 13, 2024

  Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to 1) ensure education and training was provided to all staff to provide competent, safe, and effective resident care, 2) ensure the grievance procedure was being completed in the facility and 3) ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program. 1. […]