Menifee Meadows Nursing & Rehab LLC

In the surveyor’s words

From the most serious findings on record at Menifee Meadows Nursing & Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF744Feb 22, 2023

  Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure residents with a dementia diagnosis were provided individualized care needs to ensure care and services were maintained at their highest practicable mental, physical, and psychosocial well-being, for seven (7) of twenty-one (21) sampled residents (Resident #16, Resident #18, Resident #20, Resident #4, Resident #13, Resident #17, and Resident #14) 1. On 06/23/2022, staff observed Resident #16 kissing Resident #20 while groping Resident #18's breast. Record review revealed the resident had a Dementia diagnosis and was care planned for staff to assess/monitor and document the resident's behaviors. […]

• Immediate jeopardy, patternF838Feb 22, 2023

  Based on observation, interview, and record review, it was determined the facility failed to conduct and document a facility-wide assessment to evaluate what resources were required to provide the necessary care and services for residents who required the use of a mechanical lift. On [DATE], staff transferred Resident #1 from a Geri chair to his/her bed utilizing the mechanical lift when the lift sling strap broke, and the resident fell to the concrete floor. Resident #1 fell approximately four (4) feet and sustained serious injuries which included fractures identified at C7 and T1 vertebrae and a complete break of the right humerus (upper arm bone). Resident #1 died related to his/her injuries from the fall. […]

• Immediate jeopardy, patternF908Feb 22, 2023

  Based on observation, interview, and record review, the lift's Manufacturer's Owner's Manual Safety Instructions and the Slings Manufacturer's Owner's Manual it was determined the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition regarding the mechanical lift equipment, specifically, the required lift slings for one (1) of twenty-one (21) sampled residents (Resident #1). The facility failed to follow the manufacturer's recommendations and utilized slings that were not recommended by the manufacturer. In addition, the facility failed to follow the manufacturer's maintenance recommendations for laundering and inspecting the lift slings. […]

• Immediate jeopardy, isolatedF600Feb 22, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to protect two (2) of twenty-one (21) residents (Resident #18 and Resident #20) from sexual abuse. On 06/23/2022, Resident #16 was observed by staff in the hallway, across from the nurse's station, kissing Resident #20 and groping Resident #18's breast. The facility, however, failed to assess and revise the resident's care plan to identify the potential risks to other residents related to Resident #16's behaviors. Additionally, interviews with staff revealed sexual abuse was not considered as the residents' Brief Interview for Mental Status (BIMS) score was low, or below eight (8), which indicated severe cognitive impairment. […]

• Immediate jeopardy, isolatedF609Feb 22, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report suspected abuse violations within the required timeframe and failed to implement its abuse policies and procedures for two (2) of twenty-one (21) sampled residents (Resident #18 and Resident #20). Additionally, the facility failed to identify and report to the State Agencies, resulting in failure to protect the residents from further potential abuse by the alleged perpetrator. 1. On 06/23/2022, Resident #16 was observed by staff in the hallway across from the nurse's station kissing Resident #20 and groping Resident #18's breasts. […]