Inspection Reports for Meridian Meadows Assisted Living and Memory Care
ID, 83642
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Life Safety
Deficiencies: 12
Feb 18, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Meridian Meadows Assisted Living facility.
Findings
Multiple fire and life safety deficiencies were identified including blocked electrical panels, prohibited multi-plug adapters, overdue fuel-fired heating system inspection, hazardous storage room conditions, corroded and painted sprinkler pendants, missing documentation for fire extinguisher and suppression system inspections, and prohibited use of relocatable power tap for a medical device.
Deficiencies (12)
| Description |
|---|
| Electrical panels blocked from access by furniture and landscaping tools in the back of house electrical room. |
| Use of a multi-plug adapter to supply power to a lamp, clock, and charger in room #302, which is prohibited. |
| Fuel-fired heating system inspection overdue since last documented in November 2022; annual inspection required. |
| Back of house medical records storage room larger than 50 square feet with high combustible material and lacking a self-closing door. |
| Sprinkler pendant in medical records storage room covered in non-factory applied paint/overspray and requiring replacement. |
| Corroded sprinkler pendants located in kitchen above main cook line and 3 compartment sink requiring replacement. |
| Sprinkler pendant in dish-washing area loaded with debris and requiring replacement. |
| Emergency egress and exit lighting not verified as operationally tested monthly and annually as required. |
| Annular penetration in storage closet ceiling next to room #203 eliminating smoke partition membrane continuity. |
| Lack of documentation for annual inspection of portable fire extinguishers. |
| Lack of documentation for one of two required semi-annual fire suppression system inspections and testing of UL listed hood assembly in commercial kitchen. |
| Use of relocatable power tap to supply power to an oxygen concentrator in room #307, which is prohibited. |
Report Facts
Response Due Date: Mar 20, 2025
License Number: 1228
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for the fire life safety and sanitation licensure survey |
| Tomi Mooney | Administrator | Facility administrator named in the report header |
Inspection Report
Follow-Up
Deficiencies: 6
Sep 5, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to evaluate the facility's compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility had multiple deficiencies including a consistently malfunctioning internet-based call system causing delays in resident assistance, lack of daily monitoring of medication refrigerator temperatures, outdated nursing service assessments (NSAs), inconsistent documentation of resident condition assessments, failure to document investigations of resident complaints, and unreliable internet-based phone system availability for staff.
Deficiencies (6)
| Description |
|---|
| The facility's call system was not consistently functioning, resulting in delayed responses to resident calls for assistance. |
| The facility's two medication refrigerator temperatures, containing insulin, were not monitored and documented daily. |
| Nursing Service Assessments (NSAs) were not updated to reflect significant changes in care needs or health status for sampled residents. |
| Resident care assessments were not consistently documented, including no nursing assessments for a resident who experienced nine falls. |
| The facility did not document investigations of verbal abuse accusations or written responses to resident complaints. |
| The internet-based phone system was not always available due to internet outages, and staff lacked facility phones to contact emergency services prior to deployment of cellular phones. |
Report Facts
Number of sampled residents with outdated NSAs: 9
Number of falls experienced by Resident #10: 9
Date of incident indicating immediate danger: Sep 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Mooney | Administrator | Named as the facility administrator who acknowledged call system issues and lack of front desk staff coverage |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey |
| Regional Nurse | Provided statements regarding medication refrigerator logs and resident care assessments | |
| Facility Nurse | Worked with administrator to update NSAs and assessed residents for condition changes |
Inspection Report
Life Safety
Deficiencies: 5
Mar 14, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Meridian Meadows Assisted Living.
Findings
The facility was found deficient in several areas including lack of renewed relocation agreements, missing documented inspections and testing of emergency generators, improper installation of alcohol-based hand rub dispensers, absence of documented medical gases policy, and insufficient emergency egress and relocation drills, particularly on the evening shift.
Deficiencies (5)
| Description |
|---|
| Relocation agreements have not been renewed and reviewed annually. |
| No documented weekly inspections of emergency generators from June 22 to August 31, 2022; no monthly load testing for July 2022; battery testing missed from June to December 2022. |
| Alcohol-Based Hand Rub dispensers installed less than one inch from door electric keypad, not in accordance with NFPA standards. |
| No documented policy of medical gases elimination of sources of ignition and misuse of flammable substances. |
| Only four emergency egress and relocation drills documented with only one on the night shift, fewer than required bi-monthly six drills with at least two on evening shift. |
Report Facts
Number of relocation agreements required: 2
Number of emergency egress and relocation drills required bi-monthly: 6
Number of drills documented: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Mooney | Administrator | Named as facility administrator in the report header. |
| Sam Burbank | Survey Team Leader | Named as survey team leader conducting the inspection. |
Inspection Report
Original Licensing
Deficiencies: 2
Mar 31, 2022
Visit Reason
The inspection was conducted as an initial licensure survey combined with a complaint investigation at Meridian Meadows Assisted Living.
Findings
The facility failed to ensure residents received medications and treatments as ordered by physicians, with errors in medication administration and documentation. Additionally, the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure residents received medications and treatments as ordered by the physician, including incorrect oxygen administration and missed scheduled acetaminophen and insulin doses. |
| The facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, despite noted declines and hospitalizations. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Mooney | Administrator | Named as the facility administrator in the report header. |
| Stacey Brown | Survey Team Leader | Named as the survey team leader conducting the inspection. |
Inspection Report
Life Safety
Deficiencies: 2
Mar 29, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Meridian Meadows Assisted Living.
Findings
Two non-core issues were identified: the automatic closing mechanism was removed from the door to the main kitchen from the exit corridor, and the kitchen manager was using a 3-1 extension cord for an air diffuser unit, which was corrected on site.
Deficiencies (2)
| Description |
|---|
| Door to the main Kitchen from the exit corridor on the Housekeeping side had the automatic closing mechanism removed, violating fire and life safety standards. |
| Kitchen manager using a 3-1 extension cord for air diffuser unit, corrected on site 3/29/22. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Mooney | Administrator | Named as facility administrator during the inspection. |
| Sam Burbank | Survey Team Leader | Led the fire life safety and sanitation licensure survey. |
Inspection Report
Life Safety
Deficiencies: 6
Mar 23, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Meridian Meadows Assisted Living facility.
Findings
The inspection identified multiple deficiencies related to fire and life safety standards, including inadequate relocation agreements, lack of documented emergency assembly points, missing resident inservice documentation, absence of dated fuel-fired heating inspection, insufficient fire drill documentation, and incomplete emergency generator load testing.
Deficiencies (6)
| Description |
|---|
| Only one relocation agreement with one alternate location, not dated or signed; facility requires two relocation agreements with two separate locations reviewed annually. |
| No documented point of assembly outlined in emergency plan for evacuations; emergency plan must designate a point of assembly and include it in drills. |
| No documented inservice for residents on roles and responsibilities as outlined in the emergency plan. |
| No documentation of annual fuel-fired heating inspection; documentation provided was not dated. |
| Only one documented fire drill conducted on May 4, 2020; other documentation identified as inservice and failed to document resident assembly to designated point. |
| Generator load testing not completed in accordance with NFPA 110; no documented load or exhaust temperature captured per manufacturer's specifications. |
Report Facts
Fire drill date: May 4, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tomi Mooney | Administrator | Named as facility administrator |
| Sam Burbank | Survey Team Leader | Named as survey team leader |
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