Inspection Reports for
Meridian Meadows Assisted Living and Memory Care

39-3309.01 Negotiated service agreement: residents' NSAs did not clearly reflect needs or services and were not consistently followed, including issues with assistance at bedtime, eating, and walker use (previously cited 9/05/2023).

39-3321.2.d Qualifications and requirements of administrator: the facility did not develop interventions to prevent recurrences after residents' falls, with multiple incidents lacking timely interventions.

.250.07 Heating, ventilation, and air-conditioning (HVAC): the facility failed to have the fuel fired heating system inspected and serviced annually as required.

.405.01 Electrical installations and equipment: electrical panels in the back of house electrical room were blocked from access by furniture and landscaping tools, violating clearance requirements.

.405.01.a Electrical installations and equipment: a lamp, clock, and charger in room #302 were powered by a prohibited multi-plug adapter.

.405.04 Fuel-fired heating: the last documented inspection of fuel-fired heating systems was in November 2022; annual inspections are required.

.404 Fire and life safety standards for existing buildings: the back of house medical records storage room lacked a self-closing door, sprinkler pendants were covered in paint and corroded, the dish-washing area sprinkler pendant was loaded with debris, emergency egress and exit lighting were not tested as required, and a storage closet had a penetration compromising the smoke partition membrane.

.330.15 Fire and life safety records: documentation was not provided for annual inspection of portable fire extinguishers and for one of two required semi-annual fire suppression system inspections and testing of the UL listed hood assembly in the kitchen.

.405.02.a Prohibited applications: an oxygen concentrator in room #307 was powered by a relocatable power tap, which is prohibited for medical devices.

.250.14 Call system: the facility's call system was not consistently functioning due to internet outages and phones disconnecting from wi-fi, resulting in delayed staff response to resident calls for assistance, including an immediate danger situation identified on 9/1/23.

.310.01.c Medication distribution system: the facility's two medication refrigerator temperatures containing insulin were not monitored or documented daily, with the most recent logs from March 2023.

.320.08 Periodic review: nursing service assessments were not updated to reflect significant changes in care needs or health status for 9 of 10 sampled residents, missing night needs and specific care instructions.

.330.04.c.vii Resident care records: assessments for changes in resident conditions were not consistently documented, including nine falls experienced by one resident without nursing assessments in the record.

.330.08.b Additional resident records: the facility did not document investigation of a verbal abuse accusation or written responses to resident complaints about diet and carpet stains.

.405.06 Telephone: the internet-based phone system was not always available due to internet outages, requiring staff to use personal phones for emergency calls and lacking phones for emergency contact prior to cellular phone deployment.

.155.01 Relocation agreements: the two relocation agreements had not been renewed and reviewed annually.

.155.03 Emergency generators: no documented weekly inspections from June 22 to August 5 and from August 5 to 31, 2022; no monthly load testing for July 2022; battery testing missed from June to December 2022.

.404 Fire and life safety standards for existing buildings: two alcohol-based hand rub dispensers were installed less than one inch from door electric keypads, not in accordance with NFPA 101.

.405.03 Medical gases: no documented policy for elimination of ignition sources and misuse of flammable substances as required by NFPA 99.

.410 Requirements for emergency actions and fire drills: only four drills documented with only one on the night shift, fewer than the required six bi-monthly drills including at least two on the evening shift when residents are sleeping.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure residents received medications and treatments as ordered by the physician, including incorrect oxygen administration, failure to update medication records, and delayed insulin doses.

.305.03. Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, despite hospitalizations and declines in condition.

.404. Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: door to the main kitchen from the exit corridor had the automatic closing mechanism removed; all hazardous area doors must be self-closing in accordance with NFPA 101, Chapter 33, Section 33.3.3.2.2.

.405.01.a. Electrical installations and equipment: kitchen manager was using a 3-1 extension cord for air diffuser unit; corrected on site 3/29/22.

.155.01 Relocation agreements: only one relocation agreement with one alternate location was present, not dated or signed; the facility must have two agreements with separate locations reviewed annually.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented point of assembly in the emergency plan and no documented inservice for residents on roles and responsibilities as outlined in the emergency plan.

.405.04 Fuel-fired heating: no documentation of annual fuel-fired heating inspection; documentation provided was not dated.

.410 Requirements for emergency actions and fire drills: only one documented fire drill conducted on May 4, 2020; other documentation identified as inservice failed to document actions taken including resident assembly to a designated point.

.155.03 Emergency generators: generator load testing was not completed according to NFPA 110; no documented load or exhaust temperature captured per manufacturer's specifications.