Inspection Reports for
Meadowview Healthcare and Rehab
825 North Gaskill, Huntsville, AR 72740, AR, 72740
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
26.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
406% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
46% occupied
Based on a October 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted due to an allegation of abuse reported by Resident #2, specifically that the resident was kicked by a staff member during the night shift. The investigation was initiated after the allegation was brought to the Administrator's attention by surveyors.
Complaint Details
The complaint involved an allegation by Resident #2 that a staff member kicked them during the night. The allegation was documented by LPN #1 on 11/01/2024 but was not reported to administration until 01/24/2025 after surveyors brought it to the Administrator's attention. The allegation was investigated, and the resident and responsible party were interviewed. LPN #1 received a verbal warning and retraining for failure to report the abuse allegation timely. The facility policy requires immediate reporting to the Administrator and State Agency within two hours.
Findings
The facility failed to timely report the allegation of abuse to facility administration and the State Agency as required. LPN #1 documented the allegation but did not report it to the Administrator or Director of Nursing at the time. The Administrator and DON confirmed that staff were expected to report abuse allegations immediately, and LPN #1 received retraining and disciplinary action for failing to report the incident promptly.
Deficiencies (1)
Failure to timely report suspected abuse to facility administration and the State Agency for 1 of 3 residents reviewed for abuse.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Brief Interview for Mental Status score: 14
Date of abuse allegation documentation: Nov 1, 2024
Date abuse allegation reported to Administrator: Jan 24, 2025
Date of verbal warning to LPN #1: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented abuse allegation and failed to timely report it; received retraining and verbal warning |
| Director of Nursing | Director of Nursing (DON) | Confirmed reporting expectations and retraining of LPN #1 |
| Administrator | Facility Administrator | Initiated investigation upon learning of the allegation and confirmed reporting policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted due to an allegation of abuse reported by Resident #2, which was initially not reported to facility administration or the State Agency as required.
Complaint Details
The complaint involved an allegation by Resident #2 that someone on night shift kicked them. The allegation was not reported immediately by LPN #1 as required. The allegation was later investigated and reported after surveyors brought it to the Administrator's attention. The complaint was substantiated with corrective actions including retraining and disciplinary warning for LPN #1.
Findings
The facility failed to timely report an allegation of abuse involving Resident #2. The Licensed Practical Nurse (LPN #1) documented the abuse allegation but did not report it to the Administrator or Director of Nursing (DON) as required. The facility subsequently investigated and reported the allegation after surveyors brought it to the Administrator's attention. Retraining and disciplinary action were taken against LPN #1.
Deficiencies (1)
Failure to timely report suspected abuse of Resident #2 to facility administration and the State Agency.
Report Facts
Residents reviewed for abuse: 3
Brief Interview for Mental Status score: 14
Employee disciplinary action date: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented abuse allegation but failed to report it as required; received retraining and disciplinary warning |
| Director of Nursing | Director of Nursing (DON) | Confirmed staff reporting expectations and retraining of LPN #1 |
| Administrator | Facility Administrator | Initiated investigation and reported allegation to State Agency |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding unsafe hot water temperatures, inadequate supervision to prevent accidents, and elopement risks at Meadowview Healthcare and Rehab.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy related to unsafe hot water temperatures and inadequate supervision leading to elopement risks. The Immediate Jeopardy began on 2024-10-04 and was removed for hot water issues on 2024-10-16, but remained for elopement due to lack of an acceptable removal plan.
Findings
The facility failed to maintain safe hot water temperatures, with readings up to 151°F, and did not properly document or act on these concerns. The facility also lacked adequate supervision and safety measures to prevent falls and elopement, affecting multiple residents including Resident #49 who had multiple elopements. Immediate jeopardy was identified related to hot water temperatures and elopement risks.
Deficiencies (6)
Failed to monitor and maintain safe hot water temperatures, with temperatures up to 151°F in resident areas.
Failed to implement reporting and corrective actions for hot water temperature concerns.
Failed to ensure an emergency call system accessible to residents in common bathrooms.
Failed to ensure safe and secure environment for residents with wandering and exit-seeking behaviors, affecting Resident #49.
Failed to adequately assess, establish interventions, and provide supervision to prevent falls for Residents #21 and #25.
Failed to maintain safe medication preparation practices, allowing Resident #49 to drink medication left unattended.
Report Facts
Residents affected: 48
Hot water temperature readings: 151
Falls: 63
Elopement incidents: 3
Resident census during inspection: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Provided information about Resident #49's elopement incidents and fall risk interventions for Resident #21. |
| CNA #1 | Certified Nursing Assistant | Reported identification of hot water problem and witnessed Resident #49's elopement. |
| Environmental Director | Responsible for water temperature monitoring and adjustments; provided details on hot water heater settings and mixing valve. | |
| Administrator | Notified of immediate jeopardy, provided statements regarding elopement monitoring and hot water issues. | |
| Director of Nursing (DON) | Director of Nursing | Involved in notification and education regarding hot water temperatures and resident safety. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding unsafe hot water temperatures, inadequate supervision to prevent accidents, and elopement risks at Meadowview Healthcare and Rehab.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy related to unsafe hot water temperatures and elopement risks. Multiple incidents of elopement by Resident #49 were documented, including escapes through doors and alarms. The facility failed to monitor and secure the environment adequately. Falls were frequent for Resident #21 with 63 falls documented in one year, and interventions were insufficient.
Findings
The facility failed to maintain safe hot water temperatures, which reached up to 151°F, and did not properly document or act on these concerns. The facility also lacked adequate supervision and safety measures to prevent falls and elopement, affecting multiple residents including Resident #49 who had multiple elopements. Immediate jeopardy was identified related to hot water temperatures and elopement risks.
Deficiencies (6)
Failed to monitor and maintain safe hot water temperatures up to 151°F in resident areas.
Failed to implement reporting system for hot water temperature concerns.
Failed to ensure emergency call system accessible in common bathroom.
Failed to ensure safe and secure environment for residents with wandering and exit seeking behaviors.
Failed to adequately assess, establish interventions, and provide supervision to prevent falls for 2 residents.
Failed to maintain safe medication preparation practices allowing a resident to drink medication left unattended.
Report Facts
Residents affected: 48
Hot water temperature: 151
Falls: 63
Elopement risk score: 4
Falls: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Provided information about Resident #49's elopement incidents and fall risk interventions for Resident #21. |
| Environmental Director | Responsible for water temperature monitoring and maintenance; stated water heaters set at 170°F and mixing valve adjustments. | |
| Administrator | Notified of immediate jeopardy and elopement incidents; provided information on notification procedures and facility monitoring. | |
| Director of Nursing (DON) | Director of Nursing | Notified of hot water temperature issues; described interventions for falls and resident notifications. |
| CNA #1 | Certified Nursing Assistant | Reported identification of hot water problem and involvement in elopement incident with Resident #49. |
| CNA #20 | Certified Nursing Assistant | Observed Resident #49 eloping through facility doors. |
Inspection Report
Immediate Jeopardy
Census: 48
Deficiencies: 15
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to multiple concerns including hot water temperatures causing burns, call light system failures, allegations of resident abuse, and other regulatory compliance issues.
Findings
The facility was found to have immediate jeopardy related to unsafe hot water temperatures, failure of call light systems, physical abuse of a resident during blood draw, inadequate staffing and training, failure to maintain infection control, and ineffective governance and quality assurance programs.
Deficiencies (15)
Resident #18 and #20 sustained burns from excessively hot water temperatures in resident bathrooms and showers.
Call light system was not functioning on 200 and 300 halls for at least a week, residents unable to summon assistance timely.
Certified Nursing Assistant (CNA) #1 physically restrained Resident #21 during blood draw despite resident refusal.
Facility failed to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services.
Facility failed to submit required CMS Payroll Based Journal staffing data for Q3 2024.
Facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program.
Facility failed to maintain an effective infection prevention and control program including hand hygiene and antibiotic stewardship.
Facility failed to ensure call light system was effectively working and failed to implement emergency backup system.
Facility failed to maintain an effective pest control program; mice and rodent infestations were observed and not adequately addressed.
Facility failed to ensure food was prepared and served according to menu and recipes, including overcooked squash and unmeasured pureed foods.
Facility failed to ensure proper hand hygiene and food safety practices during food preparation and service.
Facility failed to ensure smoking policy was established and followed.
Facility failed to provide required training and competency evaluations for staff including dementia care and communication.
Facility failed to ensure assessments and care plans were accurate and complete for residents including bedrail use, fall risk, and dementia care.
Facility failed to ensure governance and management oversight to implement policies and address deficiencies.
Report Facts
Residents affected by hot water burns: 2
Residents with call light issues: 4
Resident falls: 63
Residents with dementia: 28
Staff in-service training attendance: 67
Hot water temperature: 151
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Physically restrained Resident #21 during blood draw despite refusal. | |
| Phlebotomist | Drew blood from Resident #21 despite refusal and did not perform hand hygiene. | |
| Administrator | Failed to ensure timely reporting of abuse, adequate training, and governance oversight. | |
| Director of Nursing (DON) | Failed to ensure adequate staffing, training, and follow-up on call light system and abuse allegations. | |
| Environmental Director | Failed to maintain safe hot water temperatures and pest control. | |
| Kitchen Manager | Failed to follow recipes and ensure food quality and safety. | |
| Human Resource Director | Failed to ensure staff training and competency documentation. | |
| Certified Nursing Assistant (CNA) #9 | Failed to perform hand hygiene during food service. | |
| Licensed Practical Nurse (LPN) #24 | Reported lack of dementia care training and staff competency. |
Inspection Report
Immediate Jeopardy
Census: 48
Deficiencies: 13
Date: Oct 7, 2024
Visit Reason
The inspection was conducted due to multiple complaints and concerns including hot water temperatures causing burns, call light system failures, allegations of abuse, and overall facility compliance with health and safety regulations.
Findings
The facility was found to have multiple deficiencies including failure to maintain safe hot water temperatures, ineffective call light systems without emergency backup, physical abuse of a resident during blood draw, inadequate staffing and competency of nursing staff, failure to maintain infection control practices, poor food service practices, rodent infestation, lack of proper governance and quality assurance programs, and failure to provide required staff training.
Deficiencies (13)
Failure to maintain safe hot water temperatures with temperatures up to 151°F causing burns to residents.
Failure to ensure call light system was effectively working on 200 and 300 halls and lack of emergency backup system.
Physical abuse of Resident #21 by CNA #1 restraining resident during blood draw despite resident refusal.
Inadequate staffing and lack of competency training for nursing staff, including dementia care and infection control.
Failure to maintain infection control practices including hand hygiene, aseptic technique during wound care and lab draws, and lack of antibiotic stewardship program.
Failure to maintain effective pest control program resulting in rodent infestation inside the facility.
Failure to provide food as per menu and recipes, including serving overcooked and watered down food.
Failure to properly wash and sanitize food preparation utensils and improper storage of ice scoop.
Failure to properly assess and document use of bed rails as restraints and enablers, including lack of measurements and safety assessments.
Failure to post nurse staffing information daily with required details.
Failure to establish and implement effective Quality Assurance Performance Improvement (QAPI) program.
Failure to conduct required staff training including communication, compliance/ethics, and behavioral health training.
Failure to establish and implement a smoking policy.
Report Facts
Residents affected by call light failure: 48
Hot water temperature: 151
Resident falls: 63
Staff in-service attendance: 67
Staff in-service attendance: 54
Residents identified with Alzheimer's/Dementia: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Physically restrained Resident #21 during blood draw; reported abuse and training discussed |
| Administrator | Responsible for facility operations, acknowledged lack of training and policies, involved in abuse investigation and QAPI | |
| DON | Director of Nursing | Involved in abuse investigation, call light system issues, staff competency, infection control oversight |
| Environmental Director | Responsible for water temperature monitoring, pest control, and maintenance issues | |
| LPN #24 | Licensed Practical Nurse | Reported lack of CNA competencies, knowledge of THC medication, and resident elopement |
| Medical Director | Prescribed THC gummies, involved in abuse reporting, unaware of licensure limitations | |
| Board President | Governing body member, involved in financial and operational oversight | |
| HRD | Human Resource Director | Responsible for staff training and competency tracking |
| CNA #9 | Certified Nursing Assistant | Observed infection control lapses during meal service |
| Phlebotomist | Contracted lab technician involved in abuse allegation, poor infection control practices | |
| Kitchen Manager | Reported food preparation issues and training | |
| Dietary Manager | Reported food service issues and training |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Date: Dec 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a cognitively impaired resident exited the facility without staff knowledge through a door with a failed locking mechanism, resulting in the resident being missing for approximately 30 minutes and sustaining injury.
Complaint Details
The complaint investigation was substantiated. Resident #1, with a history of wandering and exit seeking, exited the facility through a door with a failed locking mechanism and was missing for approximately 30 minutes. The resident was found outside with a hematoma. Staff failed to confirm all residents were accounted for and did not reassess elopement risk or provide adequate staff training. The facility was placed in Immediate Jeopardy status.
Findings
The facility failed to ensure adequate supervision and secure locking mechanisms to prevent resident elopement, failed to reassess residents for elopement risk, and did not provide staff education or monitor door locks properly. This resulted in immediate jeopardy to resident health and safety with potential for serious harm to multiple residents.
Deficiencies (5)
Failed to ensure a cognitively impaired resident did not exit the facility without staff knowledge due to a failed door locking mechanism.
Failed to ensure all residents were accounted for and reassessed for risk of elopement after the incident.
Failed to provide staff education on elopement prevention and response.
Failed to assess or monitor all facility door locking mechanisms to prevent lock failures.
Facility elopement policy lacked clearly defined mechanisms and procedures for assessing, monitoring, and managing residents at risk for elopement.
Report Facts
Residents currently in facility: 52
Duration resident missing: 30
Date of incident: Dec 8, 2023
Date survey completed: Dec 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information on the incident, door lock failure, and corrective actions taken | |
| Registered Nurse (RN) #1 | Cared for Resident #1 at time of elopement and described incident | |
| Environmental Technician | Described door lock failure and resident elopement circumstances | |
| Director of Nursing (DON) | Described missing resident procedures and confirmed resident elopement details | |
| Environment Director | Confirmed maintenance responsibilities and door lock monitoring |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Date: Dec 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a cognitively impaired resident (Resident #1) exited the facility without staff knowledge through a door with a failed locking mechanism, resulting in the resident being missing for approximately 30 minutes and sustaining a hematoma.
Complaint Details
The complaint investigation was triggered by an incident on 12/8/23 where Resident #1 exited the building through a service corridor with a failed lock, was missing for approximately 30 minutes, and was found lying outside with a hematoma. The investigation confirmed failures in supervision, door lock maintenance, resident reassessment, and staff training. The facility was placed in Immediate Jeopardy status.
Findings
The facility failed to ensure adequate supervision and security to prevent elopement of a cognitively impaired resident, failed to reassess residents for elopement risk, failed to provide staff education, and did not monitor or maintain door locking mechanisms properly. Immediate corrective actions were taken including reassessment of all residents, staff inservice, and repair of door locks.
Deficiencies (5)
Failed to ensure a cognitively impaired resident did not exit the facility without staff knowledge due to a failed door locking mechanism.
Failed to ensure all residents were accounted for after elopement incident.
Failed to reassess residents for risk of elopement after the incident.
Failed to provide education to staff regarding elopement prevention and response.
Failed to assess or monitor the functioning of door locking mechanisms to prevent elopement.
Report Facts
Residents currently in facility: 52
Duration resident missing: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse caring for Resident #1 at time of elopement, described incident and response |
| Administrator | Facility Administrator | Provided information on incident, door lock failure, and corrective actions |
| DON | Director of Nursing | Described missing resident process and confirmed lack of reassessment and monitoring |
| Environmental Technician | Described finding resident outside and confirmed door lock failure |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, hygiene, medication management, nutrition, infection control, and facility environment at Meadowview Healthcare and Rehab.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal assistance, call lights out of reach, missing advance directives, unsafe environmental hazards, untimely facial hair removal, improper storage of respiratory equipment, unlabeled and expired medications, failure to follow menu plans, poor food handling and hygiene practices, and inadequate infection control procedures including wound care and laundry handling.
Deficiencies (10)
Staff failed to ensure residents' dignity during meal assistance by standing over residents and referring to residents as feeders.
Call light was not within reach for a resident requiring assistance.
Resident's advance directive was not completed or located upon entry.
Resident environment was unsafe with loose door protectors, protruding baseboards, holes in walls, and unsecured recliner handles.
Facial hair was not removed in a timely manner for residents requiring assistance with personal hygiene.
Nebulizer masks were stored in a manner that could cause cross contamination.
Drugs and biologicals were not labeled appropriately and expired medications were not disposed of.
Menu was not followed for residents receiving pureed diets; cornbread was omitted.
Food handling practices failed to prevent cross contamination; hand hygiene and hair covering protocols were not followed.
Infection control precautions were not followed during wound care and personal care; bed pans were improperly stored; laundry handling practices risked cross contamination.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication items observed: 5
Snack bags: 7
Nasal strips: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nursing Assistant | Named in dignity during meal assistance finding |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about resident dignity during meal assistance |
| Director of Nursing | Director of Nursing | Interviewed about dignity, infection control, and feeding practices |
| CNA #1 | Certified Nursing Assistant | Confirmed call light out of reach |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed resident ability to use call light and interviewed about nebulizer mask storage |
| Administrator | Administrator | Reported missing advance directive and confirmed environmental hazards |
| CNA #7 | Certified Nursing Assistant | Interviewed about shaving residents |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication labeling |
| Dietary Manager | Dietary Manager | Interviewed about menu adherence and food handling |
| CNA #5 | Certified Nursing Assistant | Observed and interviewed about hand hygiene during meal delivery |
| Dietary Aide #1 | Dietary Aide | Observed with poor hand hygiene and hair covering practices |
| Dietary Aide #2 | Dietary Aide | Observed with poor hand hygiene and food handling practices |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed about infection control during personal care |
| CNA #10 | Certified Nursing Assistant | Observed and interviewed about infection control during personal care |
| Laundry Employee #1 | Laundry Employee | Observed and interviewed about laundry handling and apron use |
| Laundry Employee #2 | Laundry Employee | Observed folding laundry improperly |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, call light accessibility, advance directive documentation, environmental safety hazards, personal hygiene care, respiratory care equipment storage, medication labeling and expiration, menu adherence, food safety and hygiene practices, and infection control procedures including wound care and laundry handling.
Deficiencies (10)
Failed to ensure staff did not stand over resident while assisting with meals and residents were not referred to as feeders.
Failed to ensure call light was within reach for a resident requiring assistance.
Failed to ensure a resident had completed an Advance Directive upon entry.
Failed to ensure resident's environment was safe, free of hazards, and promoting a homelike environment.
Failed to ensure facial hair was removed in a timely manner to maintain dignity for residents requiring assistance.
Failed to ensure nebulizer masks were stored to prevent cross contamination.
Failed to ensure drugs and biologicals were labeled appropriately and disposed of past expiration date.
Failed to ensure menu was followed for residents receiving pureed diet.
Failed to ensure food safety practices including hand hygiene, hair covering, proper food storage, and use-by dates were followed.
Failed to ensure infection control precautions during wound care, bed pan storage, and laundry handling to prevent cross contamination.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication expiration: 7
Use by date: 9
Number of snack bags: 7
Number of nasal strips: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nursing Assistant | Named in dignity during meal assistance finding |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about resident dignity during meal assistance |
| Director of Nursing | Director of Nursing | Interviewed about dignity during meal assistance and infection control |
| CNA #1 | Certified Nursing Assistant | Confirmed call light accessibility issue |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed resident's ability to use call light and interviewed about nebulizer mask storage |
| Administrator | Administrator | Reported missing advance directive |
| CNA #7 | Certified Nursing Assistant | Interviewed about shaving residents |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication labeling |
| Dietary Manager | Dietary Manager | Interviewed about menu adherence and food safety practices |
| CNA #5 | Certified Nursing Assistant | Observed and interviewed about hand hygiene during meal tray delivery |
| Dietary Aide #1 | Dietary Aide | Observed with hair uncovered and improper hand hygiene |
| Dietary Aide #2 | Dietary Aide | Observed with improper hand hygiene and food handling |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed about infection control during personal care |
| CNA #10 | Certified Nursing Assistant | Observed and interviewed about infection control during personal care |
| Laundry Employee #1 | Laundry Employee | Observed and interviewed about laundry infection control practices |
| Laundry Employee #2 | Laundry Employee | Observed and interviewed about laundry infection control practices |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care standards following observations, record reviews, and interviews related to treatment, medication administration, and behavioral management of residents.
Findings
The facility failed to notify the physician timely about changes in Resident #1's condition and failed to ensure correct medication dosage administration for Resident #3, resulting in a medication error. Additionally, the facility did not adequately address Resident #2's behavioral issues in a timely manner, causing injury to one resident and placing others at risk.
Deficiencies (3)
Failed to notify physician of changes in Resident #1's condition related to eye injury and pain.
Failed to ensure correct dosage of physician-ordered medication for Resident #3, resulting in medication error with Hydromorphone (Dilaudid).
Failed to address behavioral symptoms of Resident #2 in a timely manner, causing injury to one resident and risk to others.
Report Facts
Residents sampled: 7
Medication doses given: 2
Dates of behavioral incidents: Apr 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Involved in medication error with Resident #3's Hydromorphone dosage. |
| RN #1 | Registered Nurse | Discovered medication error with Resident #3 and reported it to DON. |
| DON | Director of Nursing | Interviewed regarding Resident #1's eye injury and Resident #3's medication error. |
| Administrator | Interviewed regarding facility policies and incidents involving Residents #1, #2, and #3. | |
| CNA #1 | Certified Nursing Assistant | Interviewed about handling Resident #2's aggressive behavior. |
| CNA #2 | Certified Nursing Assistant | Interviewed about Resident #2's threats and incidents. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #3's medication error and handling aggressive residents. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of changes in resident conditions and medication errors, as well as failure to address behavioral issues in a timely manner causing injury and risk to residents.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving Resident #1's injury and lack of physician notification, Resident #3's medication error, and Resident #2's aggressive behaviors causing injury and risk to others. Substantiation status is not explicitly stated.
Findings
The facility failed to notify the physician of changes in Resident #1's condition and administered incorrect medication dosage to Resident #3. Additionally, the facility failed to manage Resident #2's behavioral disturbances timely, resulting in injury to another resident and placing others at risk.
Deficiencies (3)
Failed to ensure physician notification of changes for Resident #1 after injury and complaints of eye pain and pressure.
Failed to ensure correct dosage administration of physician-ordered medication (Dilaudid) for Resident #3, resulting in medication error.
Failed to address behavioral disturbances of Resident #2 in a timely manner, causing injury to Resident #1 and placing other residents at risk.
Report Facts
Residents sampled: 7
Medication orders: 3
Medication doses given: 8
Behavior monitoring duration: 24
Depakote dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Involved in medication error with Resident #3's Dilaudid order |
| RN #1 | Registered Nurse | Discovered medication error with Resident #3's Dilaudid order |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #3's medication error and behavior management |
| Director of Nursing | Director of Nursing | Interviewed about Resident #1's eye injury and Resident #3's medication error |
| Administrator | Administrator | Interviewed about Resident #1's eye injury, Resident #3's medication error, and behavioral management of Resident #2 |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 13
Date: Jul 8, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including medication management, care planning, pressure ulcer care, infection control, and other resident care standards.
Findings
The facility was found deficient in multiple areas including inaccurate medication assessments, incomplete care plans, inadequate pressure ulcer documentation and care, unsafe laundry practices, improper catheter care, inconsistent oxygen therapy, improper medication storage, food safety violations, inadequate infection control practices especially related to COVID-19, and failure to timely notify residents and families of COVID-19 infections.
Deficiencies (13)
Failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 resident receiving Plavix.
Failed to ensure care plans were updated to include current treatments and medications for residents receiving anticoagulant, oxygen, and insulin therapy.
Failed to ensure development of a discharge summary including recapitulation of resident's stay and final status for 1 discharged resident.
Failed to document weekly pressure ulcer wound assessments including measurements and wound characteristic changes for 1 resident with a stage III pressure ulcer.
Failed to ensure clothes dryers were free of lint build-up to reduce fire risk in laundry room.
Failed to provide appropriate catheter care and incontinent care to prevent urinary tract infections for 2 residents.
Failed to maintain physician ordered oxygen flow rate consistently for 1 resident using oxygen therapy.
Failed to ensure physician re-evaluation every 14 days for as needed antianxiety medication for 1 resident.
Failed to ensure medications were labeled and stored according to law and accepted pharmacy principles; found unlabeled magnesium citrate bottle in medication refrigerator.
Failed to ensure food items in kitchen were properly labeled, dated, and expired items discarded; sanitizer levels in dishwashing below required ppm; improper food storage and sanitation practices observed.
Failed to implement effective QAPI and QAA activities to correct repeated deficiencies in medication storage and respiratory care.
Failed to ensure proper infection prevention and control practices including consistent and correct mask wearing by staff, visitors, and residents during a COVID-19 outbreak.
Failed to timely notify residents and families of confirmed COVID-19 infections within required timeframe.
Report Facts
Residents affected: 46
Medication administration frequency: 9
Medication administration frequency: 19
Medication administration frequency: 20
Medication administration frequency: 9
Medication administration frequency: 3
Medication administration frequency: 13
Medication administration frequency: 11
Medication administration frequency: 6
Medication administration frequency: 7
Medication administration frequency: 6
Medication administration frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Tested positive for COVID-19 on 6/25/22 and delayed notification to facility. | |
| Director of Nursing | DON | Interviewed regarding care plan responsibilities, medication storage, and infection control deficiencies. |
| Licensed Practical Nurse #3 | LPN | Observed setting oxygen concentrator flow rate and interviewed about oxygen therapy. |
| Laundry Worker #3 | Observed wearing mask under nose and interviewed about mask use. | |
| Administrator | Interviewed about infection control policies, QAPI, and COVID-19 notification procedures. | |
| Infection Control Preventionist | ICP | Interviewed about infection control policies and mask use. |
| Certified Nursing Assistant #1 | CNA | Observed providing incontinent care with improper cleaning technique. |
| Registered Nurse #1 | RN | Interviewed about peri care and potential complications of improper cleaning. |
Inspection Report
Routine
Census: 46
Deficiencies: 14
Date: Jul 8, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, care planning, pressure ulcer care, infection control, and other resident care standards.
Findings
The facility was found deficient in multiple areas including inaccurate medication assessments, incomplete care plans for anticoagulant, oxygen, and insulin therapies, inadequate pressure ulcer documentation and care, unsafe laundry room conditions, improper catheter care, inconsistent oxygen therapy administration, failure to re-evaluate PRN antianxiety medication timely, improper medication storage and labeling, food safety violations, inadequate infection control practices including improper mask use, and failure to timely notify residents and families of COVID-19 infections.
Deficiencies (14)
Failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based on pharmaceutical category for residents receiving anticoagulants.
Failed to update care plans to include current treatments and medications for anticoagulant, oxygen, and insulin therapies.
Failed to ensure development of discharge summary including recapitulation of resident's stay and final status.
Failed to document weekly pressure ulcer wound assessments including measurements and wound characteristic changes.
Failed to ensure clothes dryers were free of lint buildup to prevent fire hazard.
Failed to provide appropriate catheter care and prevent urinary tract infections including catheter bag and tubing placement.
Failed to ensure appropriate peri care cleaning to prevent urinary tract infections.
Failed to maintain physician ordered oxygen flow rate consistently for residents using oxygen therapy.
Failed to ensure PRN antianxiety medication was re-evaluated by physician every 14 days.
Failed to ensure medications were labeled and stored according to state law and pharmacy principles.
Failed to ensure food safety including proper labeling, dating, storage, and sanitization of dishes.
Failed to implement effective QAPI and QAA activities to correct repeated deficiencies in medication storage and respiratory care.
Failed to implement proper infection prevention and control practices including consistent mask use by staff and visitors.
Failed to timely notify residents and families of confirmed COVID-19 infections by 5 p.m. the next calendar day.
Report Facts
Residents affected: 46
Medication administration count: 9
Medication administration count: 19
Medication administration count: 20
Medication administration count: 9
Medication administration count: 3
Medication administration count: 13
Medication administration count: 11
Medication administration count: 6
Medication administration count: 7
Medication administration count: 6
Medication administration count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Tested positive for COVID-19 on 6/25/22 and delayed notifying facility. | |
| Director of Nursing | DON | Interviewed regarding care plan updates, oxygen therapy, medication storage, and infection control. |
| Licensed Practical Nurse #1 | LPN | Provided wound care to Resident #27 and documented wound status. |
| Registered Nurse #1 | RN | Interviewed about peri care and wound care for Resident #27. |
| Maintenance Supervisor | Interviewed about laundry lint trap cleaning and laundry room door security. | |
| Administrator | Interviewed about infection control policies, QAPI, and COVID-19 notification procedures. | |
| Infection Control and Prevention Nurse/Quality Assurance Nurse | Responsible for pressure ulcer measurements and infection control practices. | |
| MDS Coordinator | Responsible for care plan accuracy and updating interventions. |
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