Inspection Reports for
Meridian Rehabilitation & Health Care Center
1555 N. MERIDIAN STREET, WICHITA, KS, 67203-1998
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
32.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
437% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
91% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 6
Date: Aug 5, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident care, including failure to include a resident in care planning, failure to ensure residents' rights to personal possessions, neglect related to elopement and suicidal ideation, and medication availability issues.
Complaint Details
The investigation was complaint-driven, focusing on Resident 61's exclusion from care planning, residents' rights violations, neglect of Resident 53 including failure to prevent elopement and respond to suicidal ideation, and medication availability issues. The facility was found to have immediate jeopardy related to Resident 53's elopement and subsequent suicide.
Findings
The facility failed to include Resident 61 in care planning, failed to ensure residents' rights to retain and use personal possessions, neglected cognitively impaired Resident 53 leading to elopement and suicide, failed to provide adequate supervision to prevent elopement, and failed to ensure timely medication availability for Resident 61.
Deficiencies (6)
F 0553: The facility failed to include Resident 61 in the development and planning of the resident's care plan quarterly, placing the resident at risk of impaired care and autonomy.
F 0557: The facility failed to ensure residents' rights to retain and use personal possessions, including Resident 63's motorized wheelchair and Resident 54's missing coat, placing residents at risk for decreased psychosocial well-being.
F 0600: The facility failed to prevent neglect of cognitively impaired Resident 53, who eloped and later died by suicide, placing the resident in immediate jeopardy.
F 0689: The facility failed to provide adequate supervision to Resident 53, a high risk for elopement, who was found approximately two miles away from the facility, placing the resident in immediate jeopardy.
F 0742: The facility failed to provide appropriate treatment and services to Resident 53 with mental health diagnoses, including failure to respond to suicidal ideation, resulting in immediate jeopardy and the resident's death by suicide.
F 0755: The facility failed to ensure Resident 61's medication was available for administration without missed doses, placing the resident at risk of unnecessary complications.
Report Facts
Resident census: 96
Residents in sample: 20
Residents affected: 4
Medication hold days: 5
Distance eloped: 2
Fence height: 6
Temperature: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported staff should invite Resident 61 to care plan and verified lack of documentation |
| Administrative Staff A | Administrator | Confirmed findings related to Resident 63's wheelchair and Resident 54's coat |
| Social Service Staff X | Social Service Staff | Reported on Resident 61 care plan participation and Resident 63's wheelchair location |
| Physician Extender TT | Physician Extender | Provided psychiatric care and medication orders for Resident 53 |
| Certified Nurse Aide M | Certified Nurse Aide | Unaware of Resident 63's electric wheelchair |
| Licensed Nurse I | Licensed Nurse | Involved in Resident 53 elopement response and care |
| Administrative Nurse F | Administrative Nurse | Assessed Resident 53 for exit seeking behaviors and supervised care |
Inspection Report
Census: 96
Deficiencies: 15
Date: Aug 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, activities, environment, and staff training.
Findings
The facility had multiple deficiencies including failure to involve residents in care planning, failure to ensure resident rights to personal possessions, failure to accommodate bathing preferences, inaccurate assessments, inadequate supervision of an elopement risk resident resulting in immediate jeopardy, medication availability issues, food temperature and preference violations, inadequate ventilation in the beauty shop, lack of staff training and evaluations, and failure to provide consistent activities.
Deficiencies (15)
F 0553: The facility failed to include Resident R61 in the development and planning of the resident's care plan quarterly, placing the resident at risk of impaired care and autonomy.
F 0557: The facility failed to ensure residents' rights to retain and use personal possessions for Residents R63 and R54, including failure to provide access to a motorized wheelchair and timely return of a missing coat.
F 0561: The facility failed to provide choices and accommodate bathing preferences for Residents R92, R73, R74, and R81, resulting in inadequate personal hygiene and resident dissatisfaction.
F 0582: The facility failed to notify Resident R22 of Medicare Advance Beneficiary and Medicare Non-Coverage Notices as required before discharge.
F 0584: The facility failed to provide a safe, functional, sanitary, and comfortable environment for 28 residents who smoked, including unclean designated smoking areas and a service hallway in need of cleaning and repairs.
F 0600: The facility failed to prevent neglect of cognitively impaired Resident R53, who eloped and later died by hanging, despite known suicidal ideation and elopement risk, placing the resident in immediate jeopardy.
F 0641: The facility failed to accurately complete Minimum Data Set (MDS) assessments for Residents R28, R47, R41, R54, and R82, including inaccurate medication and fall documentation, risking uncommunicated care needs.
F 0657: The facility failed to review and revise care plans for Residents R92, R73, R74, R81, and R54 related to bathing preferences and falls, resulting in inadequate care planning and risk of falls.
F 0677: The facility failed to ensure necessary services to maintain good personal hygiene for Residents R92, R73, R74, R81, and R82, including bathing, nail care, hair care, and facial hair removal.
F 0689: The facility failed to ensure Resident R61's HIV medications were available for administration without missed doses, risking unnecessary complications.
F 0804: The facility failed to serve food that was palatable and at safe and appetizing temperatures, including serving cold foods above recommended temperatures and mixing cold and hot foods on the same plate.
F 0806: The facility failed to honor a food preference for Resident R41 by serving pork despite documented no pork preference, risking inadequate care.
F 0923: The facility failed to provide adequate ventilation in the beauty shop to promote good air circulation as required.
F 0947: The facility failed to develop, implement, and maintain an in-service training program to ensure five sampled CNAs completed required 12-hour annual education, risking decreased quality of care.
F 0949: The facility failed to develop, implement, and maintain an effective behavioral health training program for all staff, placing all residents at risk of not reaching their highest practicable well-being.
Report Facts
Resident census: 96
Residents in sample: 20
Medication administration record missing signatures: 62
Cold food temperature: 61.4
Cold food temperature: 58.1
Bathing frequency: 3
Bathing frequency: 5
Bathing frequency: 5
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an elopement incident involving a cognitively impaired resident who left the facility without staff knowledge.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent elopement of Resident R1 on 07/27/23. The resident left the facility unnoticed and was outside for about one hour in unsafe conditions. The facility implemented corrective actions including staff re-education, door code changes, and one-on-one supervision after the incident.
Findings
The facility failed to provide adequate supervision to prevent an elopement of a cognitively impaired, independently mobile resident with a history of elopement. The resident left the facility unnoticed, walked 0.8 miles in extreme heat, and was outside for approximately one hour before returning safely after a neighbor alerted staff.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent elopement of a cognitively impaired resident who left the facility without staff knowledge on 07/27/23, placing the resident in immediate jeopardy.
Report Facts
Resident census: 88
Distance walked by resident: 0.8
Temperature: 100
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an elopement incident involving a cognitively impaired resident who left the facility without staff knowledge.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent an elopement of a resident at risk. The deficient practice was deemed immediate jeopardy but was corrected prior to the surveyor's entrance.
Findings
The facility failed to provide adequate supervision to prevent an elopement of a cognitively impaired, independently mobile resident with a history of elopement. The resident left the facility unnoticed, walked 0.8 miles in extreme heat, and returned after about one hour, placing the resident in immediate jeopardy.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent an elopement of a cognitively impaired resident who left the facility without staff knowledge on 07/27/23.
Report Facts
Resident census: 88
Distance walked by resident: 0.8
Temperature: 100
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Jun 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors involving failure to administer ordered sodium chloride to a resident, resulting in serious health consequences.
Complaint Details
The investigation was complaint-related due to medication administration errors. The complaint was substantiated as the facility failed to notify the physician of medication refusals and shortages, causing harm to the resident.
Findings
The facility failed to administer sodium chloride as ordered to one resident, did not notify the physician of multiple refusals and medication unavailability, which caused seizures and hospitalization. The deficient practice placed the resident in immediate jeopardy and remained at a G scope and severity after removal of immediacy.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors by not administering sodium chloride as ordered and not notifying the physician of refusals and medication shortages. This resulted in seizures and hospitalization for the resident.
Report Facts
Resident census: 86
Sodium chloride refusals: 12
Sodium chloride refusals: 16
Sodium chloride missed doses: 4
Sodium chloride missed doses: 3
Resident sodium level: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician GG | Physician | Interviewed regarding lack of notification of medication refusals |
| Certified Medication Aide M | Certified Medication Aide | Interviewed about medication refusal notification process |
| Administrative Nurse D | Administrative Nurse | Interviewed about nurse responsibilities for notifying physician and pharmacy |
Inspection Report
Deficiencies: 0
Date: Jun 19, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Meridian Rehabilitation and Health Care Center, related to a regulatory survey completed on June 19, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow a resident to return from acute care and issues with discharge documentation and Minimum Data Set (MDS) accuracy.
Complaint Details
The complaint involved the facility's refusal to allow a resident to return from acute care and inaccuracies in the resident's discharge MDS. The complaint was substantiated with findings that the resident was not allowed to return and the discharge MDS was inaccurate.
Findings
The facility failed to allow one resident to return from acute care despite readiness, did not provide the required 30-day discharge notice, and lacked a policy on facility-initiated discharges. Additionally, the facility failed to complete an accurate discharge MDS for the resident.
Deficiencies (2)
F 0622: The facility did not transfer or discharge a resident with adequate reason and failed to provide required documentation and specific information upon discharge or transfer.
F 0636: The facility failed to complete an accurate Minimum Data Set (MDS) for one resident regarding discharge location and anticipation of return.
Report Facts
Resident census: 88
Residents sampled: 8
Residents reviewed for discharge: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided statements regarding resident's ER visit and facility refusal to allow return | |
| Administrative Nurse E | Stated the discharge MDS was inaccurate | |
| Administrative Staff A | Confirmed facility did not initiate discharge and refused resident's return |
Inspection Report
Routine
Census: 92
Deficiencies: 25
Date: Dec 13, 2022
Visit Reason
Routine inspection of Meridian Rehabilitation and Health Care Center to assess compliance with regulatory requirements across multiple domains including resident rights, environment, abuse prevention, care planning, medication management, infection control, and quality assurance.
Findings
The facility had multiple deficiencies including failure to promptly address resident council concerns, maintain a sanitary environment, prevent neglect and resident-to-resident abuse, provide consistent bathing, ensure wheelchair safety, provide appropriate respiratory and dialysis care, assess side rail safety, provide person-centered dementia care, employ a certified dietary manager, maintain sanitary kitchen conditions, implement a water management program, provide required immunizations, and maintain an effective quality assurance program.
Deficiencies (25)
F 0565: The facility failed to act promptly on resident council concerns about care and life issues, risking decreased quality of care and services.
F 0584: The facility failed to provide housekeeping services to maintain a sanitary environment on the memory care unit, resulting in intense urine odor.
F 0600: The facility failed to prevent neglect of Resident R36 and resident-to-resident abuse by Resident R194, placing residents at risk for injury and impaired well-being.
F 0609: The facility failed to timely report incidents of resident-to-resident abuse involving Resident R194 to the state agency as required.
F 0610: The facility failed to investigate incidents of resident-to-resident abuse involving Resident R194, risking ongoing abuse or mistreatment.
F 0625: The facility failed to provide bed hold notice to Resident R51 upon hospital admission twice, risking impaired rights to return to her room.
F 0655: The facility failed to develop a baseline care plan for Resident R293 addressing immediate health and safety needs including dietary, ADL assistance, communication, and respiratory care.
F 0656: The facility failed to develop and implement comprehensive care plans for Residents R72 and R293 addressing diabetic, wound care, respiratory, dietary, and communication needs.
F 0677: The facility failed to provide consistent bathing for Residents R16 and R35, placing them at risk for impaired dignity and skin issues.
F 0686: The facility failed to involve the Registered Dietician for nutritional interventions for Resident R72's pressure ulcer, risking worsening skin issues.
F 0689: The facility failed to ensure wheelchair brakes were functioning for Resident R35, resulting in a fall and femur fracture.
F 0695: The facility failed to provide adequate respiratory care for Resident R51's supplemental oxygen therapy, including cleaning and maintenance of equipment.
F 0698: The facility failed to provide appropriate dialysis care for Resident R34, including routine assessment of dialysis access and communication with the dialysis center.
F 0700: The facility failed to complete an assessment for safe use of side rails for Resident R33, placing the resident at risk for entrapment and injury.
F 0744: The facility failed to provide person-centered dementia care for Resident R194 with multiple behavioral incidents and resident-to-resident altercations.
F 0755: The facility failed to monitor medication room refrigerator temperatures and left a medication cart unlocked and unattended, risking medication safety.
F 0756: The facility failed to ensure the medication regimen review by the Consultant Pharmacist was reviewed and acted upon for Resident R36.
F 0757: The facility failed to notify the physician of elevated blood sugars for Resident R72 and failed to complete physician ordered labwork for Resident R36.
F 0801: The facility failed to employ a full-time Certified Dietary Manager for 92 residents, risking inadequate nutrition.
F 0807: The facility failed to ensure Resident R86 received drinks consistent with her preferences, denying milk at lunch despite requests.
F 0812: The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen and dining room, risking contaminated food.
F 0868: The facility failed to maintain an effective Quality Assessment and Assurance program to identify and correct quality deficiencies.
F 0880: The facility failed to adhere to infection control practices for COVID-19 droplet precautions and failed to implement a water management program for Legionella.
F 0883: The facility failed to obtain immunization status, provide immunization, or obtain informed declination for influenza and pneumococcal vaccines for five residents.
F 0887: The facility failed to obtain immunization status, provide immunization, or obtain informed declination for COVID-19 vaccine for three residents.
Report Facts
Residents present: 92
Residents in sample: 22
Residents on memory care unit: 13
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 5
Elevated blood sugar readings: 6
Days without bathing: 30
Days without bathing: 27
Residents positive for COVID-19: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported multiple deficiencies and investigations |
| Certified Medication Aide PP | CMA | Reported medication room temperature logs not completed |
| Dietary Staff BB | Dietary Staff | Reported kitchen sanitation issues and dietary manager status |
| Consultant RD GG | Registered Dietician | Reported not notified of pressure ulcer nutritional needs |
| Licensed Nurse H | Licensed Nurse | Reported on resident behaviors and abuse incidents |
| Certified Nurse Aide O | CNA | Reported bathing refusals and shower attempts |
| Maintenance Staff U | Maintenance Staff | Reported water management program not implemented |
| Consultant KK | Consultant Nurse | Reported expectations for wheelchair maintenance |
| Administrative Staff A | Administrator | Reported QAPI activities and facility concerns |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Apr 22, 2021
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation & Health Care Center in response to deficiencies identified during a survey conducted on 04/22/2021.
Findings
The Plan of Correction addresses multiple deficiencies including documentation of code status and advance directives, personal privacy and confidentiality of records, quality of care related to hospice and skin assessments, prevention and treatment of pressure ulcers, respiratory care, pharmacy services, medication error rates, and infection prevention and control.
Deficiencies (8)
F578 – Code status documentation was incomplete or outdated for several residents and required updates and audits to ensure accuracy.
F583 – Resident health information was not consistently protected, requiring staff education and monitoring to ensure computer screens are locked when unattended.
F684 – Hospice care orders and skin discoloration monitoring were insufficiently documented, necessitating education and audits for compliance.
F686 – Skin breakdown prevention and treatment documentation needed improvement, with audits and education planned for licensed nurses.
F695 – Respiratory care orders were incomplete or unclear, requiring education and audits to ensure proper documentation and care delivery.
F755 – Medication availability and timely reordering processes required staff education and daily reviews to prevent shortages.
F759 – Medication error rates of 5% or more were a concern, prompting education and monitoring to maintain error-free medication administration.
F880 – Infection prevention practices for mechanical lifts and glucometers were enhanced through staff education, competency checks, and frequent audits.
Report Facts
Substantial compliance date: May 14, 2021
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 8
Date: Apr 22, 2021
Visit Reason
Annual health resurvey inspection of Meridian Rehabilitation and Health Care Center to assess compliance with regulatory requirements related to resident rights, privacy, care, medication administration, infection control, and other standards.
Findings
The facility had multiple deficiencies including failure to document advance directives timely, failure to secure resident health information, inadequate documentation and monitoring of skin discoloration and hospice care, failure to provide ordered skin treatments, failure to provide respiratory care orders, medication administration errors due to untimely reordering, and failure to disinfect reusable equipment between residents.
Deficiencies (8)
F 0578: The facility failed to timely document code status and advance directives for residents R46, R81, and R51, resulting in lack of resident choice and incomplete documentation.
F 0583: The facility failed to ensure privacy of resident health information when staff left computer screens unlocked and exposed protected health information.
F 0684: The facility failed to document and monitor discoloration of resident R22's legs and feet and failed to clearly identify hospice orders for resident R285.
F 0686: The facility failed to provide and document ordered skin breakdown prevention and treatments for resident R25, with multiple missed applications and checks.
F 0695: The facility failed to provide respiratory care consistent with professional standards for resident R48 by not obtaining an order for oxygen therapy and not filling the humidifier.
F 0755: The facility failed to ensure an effective pharmaceutical system to prevent missed medication doses for resident R79 due to failure to reorder timely.
F 0759: The facility failed to maintain medication error rates below 5%, with a 28.57% error rate due to missed doses for resident R79.
F 0880: The facility failed to disinfect reusable equipment, including a mechanical lift and glucometer, after use between residents.
Report Facts
Residents census: 83
Residents sampled: 19
Medication administrations observed: 28
Medication errors: 8
Medication error rate: 28.57
Missed medication doses: 7
Missed skin treatment applications: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Interviewed regarding code status documentation, privacy expectations, hospice care, respiratory care orders, medication administration, and infection control | |
| Licensed Nurse F | Interviewed regarding respiratory care orders and medication reorder for R79 | |
| Certified Medication Aide G | Interviewed regarding medication reorder and oxygen humidifier filling | |
| Licensed Nurse J | Interviewed regarding hospice care for R285 | |
| Certified Nurse Aide H | Observed and interviewed regarding failure to disinfect mechanical lift |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 8
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as part of a Health Resurvey and Complaint Investigations at Meridian Rehabilitation and Health Care Center.
Findings
The facility had multiple deficiencies including failure to properly document advance directives, maintain resident privacy, provide quality care and hospice documentation, prevent skin breakdown, provide respiratory care, ensure timely medication administration, maintain medication error rates below 5%, and properly disinfect reusable equipment between residents.
Deficiencies (8)
F578: The facility failed to give three residents the choice to participate or refuse to participate in advance directives, including missing code status documentation and unsigned DNR forms.
F583: The facility failed to ensure the security of residents' protected health information by leaving computer screens unlocked and exposed.
F684: The facility failed to clearly identify hospice orders for one resident and failed to document leg discoloration for another resident.
F686: The facility failed to ensure staff documented and completed skin breakdown prevention and treatment interventions as ordered for one resident.
F695: The facility failed to provide respiratory care consistent with professional standards for one resident by not filling the humidifier and lacking a current oxygen order.
F755: The facility failed to ensure an effective pharmaceutical system to prevent missed medication administrations due to untimely reordering for one resident.
F759: The facility failed to maintain medication error rates below 5%, with a 28.57% error rate due to missed doses for one resident.
F880: The facility failed to ensure staff properly disinfected reusable equipment, including mechanical lifts and glucometers, after use between residents.
Report Facts
Resident census: 83
Sampled residents: 19
Medication administrations: 28
Medication errors: 8
Medication error rate: 28.57
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 30, 2019
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-11-07.
Findings
All deficiencies have been corrected as of the compliance date of 2019-12-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Nov 21, 2019
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey that exited on 2019-11-21 at Meridian Rehabilitation & Health Care Center.
Findings
The facility submitted corrective actions addressing deficiencies related to enteral feeding tube care, nursing coverage by the Director of Nursing, insulin pen labeling, and cleanliness of feeding pump poles. The plan includes education, audits, and ongoing QA committee review to ensure compliance.
Deficiencies (4)
F693-D: The facility is providing the standard of care for resident #1 enteral feeding tube. Any resident with an enteral feeding tube is at risk for this alleged deficient practice.
F727-E: The facility is providing nursing coverage for all residents by ensuring adequate nurse guidance and leadership by the Director of Nursing. Any resident is at risk for this alleged deficient practice.
F761-D: The facility has labeled all insulin pens with either an open date or discard by dates and follows manufacturers guidelines for retention after opening. Any resident requiring insulin is at risk for this alleged deficient practice.
F880-D: All tube feeding pumps and poles are clean and have a cleaning schedule developed for ongoing monitoring. Any resident requiring feeding pumps is at risk for this alleged deficient practice.
Report Facts
Audit frequency: 2
Audit frequency: 3
Audit frequency: 5
Audit duration: 8
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 4
Date: Nov 7, 2019
Visit Reason
This was a non-compliance revisit inspection to verify correction of previously cited deficiencies related to tube feeding management, staffing, medication labeling, and infection control.
Findings
The facility failed to ensure proper care of a resident's enteral feeding tube, adequate licensed nurse staffing, proper labeling of insulin pens, and maintenance of cleanliness of tube feeding pumps and poles, increasing risk of infection.
Deficiencies (4)
CFR 483.25(g)(4)-(5): The facility failed to ensure standard of care for resident R1's gastric feeding tube when staff placed a leaking feeding tube in a plastic bag without replacing the missing plug before dialysis, causing wet clothing and refusal of dialysis service.
CFR 483.35(b)(1)-(3): The facility failed to provide adequate licensed nurse staffing on 10/20/19, 10/21/19, and 10/28/19, resulting in the Director of Nursing working the floor as charge nurse despite census over 60 residents.
CFR 483.45(g)(h)(1)(2): The facility failed to properly label two insulin pens with an open or discard by date, risking medication safety.
CFR 483.80(a)(1)(2)(4)(e)(f): The facility failed to develop a cleaning schedule and provide ongoing monitoring for cleanliness of tube feeding pumps and poles, resulting in dried, spilled feeding formula on equipment and floors, increasing infection risk.
Report Facts
Resident census: 89
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Director of Nursing | Named in findings related to staffing shortages and feeding tube care |
| Licensed Nurse J | Licensed Nurse | Observed providing feeding tube care |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed regarding resident care and feeding tube issues |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding medication labeling and feeding tube cleanliness |
| Administrative Staff A | Administrative Staff | Interviewed regarding staffing and infection control |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Date: Oct 16, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to provide necessary respiratory care, specifically supplemental oxygen management for a resident.
Complaint Details
The citation represents the finding of complaint investigation KS00146720. The facility failed to provide necessary services related to supplemental oxygen by the failure of staff to change the oxygen tank before it ran out of oxygen for one resident.
Findings
The facility failed to ensure continuous oxygen flow for a resident by not changing the oxygen tank before it ran out. Staff did not monitor oxygen tank levels adequately, resulting in interrupted oxygen supply to the resident.
Deficiencies (1)
Respiratory care regulation 483.25(i) was not met as staff failed to change the oxygen tank before it ran out, interrupting oxygen supply to a resident requiring continuous oxygen.
Report Facts
Resident census: 95
Residents sampled: 3
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 16, 2019
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey conducted on 2019-10-16 at Meridian Rehabilitation & Health Care Center.
Findings
The facility was found deficient in respiratory/tracheostomy care and suctioning practices, specifically regarding timely switching of oxygen tanks. The Plan of Correction outlines corrective actions including staff education and ongoing audits to ensure compliance.
Deficiencies (1)
F695- Respiratory/Tracheostomy Care and Suctioning: Resident #3’s oxygen tank was not switched out timely when low or empty. Staff will be educated on e-tank management and audits will be conducted to ensure compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 22, 2019
Visit Reason
A revisit survey was conducted on 8/21/19-8/22/19 for all previous deficiencies cited on 6/26/19.
Findings
All deficiencies have been corrected as of the compliance date of 7/31/19 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 15
Date: Jul 12, 2019
Visit Reason
Complaint investigations were conducted based on multiple complaint numbers related to resident care and facility conditions.
Complaint Details
The inspection was conducted in response to multiple complaint investigations related to resident care, medication errors, infection control, and environmental conditions.
Findings
The facility failed to treat residents with respect and dignity during care, failed to provide adequate care to prevent and treat pressure ulcers, failed to provide adequate supervision and fall prevention, failed to properly manage medications, failed to employ qualified dietary staff and follow nutritional guidelines, failed to maintain infection control practices, and failed to provide a safe and sanitary environment.
Deficiencies (15)
F 557: The facility failed to treat resident #1 with respect and dignity by exposing the resident's body during incontinence care in full view of the roommate and failed to maintain dignity for resident #5 by not shaving facial hair and not cleaning soiled clothing.
F 677: The facility failed to provide necessary services to maintain good nutrition, grooming, and hygiene for residents #1, #3, and #5, including missed baths, inadequate shaving, and failure to reposition and change incontinence products timely.
F 686: The facility failed to provide care to prevent and promote healing of pressure ulcers for residents #1 and #5, including timely repositioning, incontinence care, and avoiding pressure on wounds.
F 689: The facility failed to provide adequate supervision and assistive devices to prevent accidents for residents #1, #3, and #7, including improper transfer techniques and failure to assess causal factors after falls.
F 690: The facility failed to care for resident #1's indwelling catheter properly following bowel incontinence, increasing risk of infection.
F 697: The facility failed to manage pain for resident #1 during transfer and incontinence care, leaving the resident suspended in a sit to stand lift for 18 minutes despite verbal and non-verbal pain indicators.
F 725: The facility failed to have sufficient nursing staff with appropriate competencies and skill sets to provide nursing care to all residents, resulting in inadequate care and medication errors.
F 726: The facility failed to ensure licensed nurses had the competencies and skill sets necessary to care for residents, including a significant medication error where resident #2 received 8 times the ordered dose of Clonidine.
F 760: The facility failed to ensure residents were free of significant medication errors, including administering 8 times the ordered dose of Clonidine to resident #2 and administering insulin to resident #5 without an order or diagnosis of diabetes.
F 801: The facility failed to employ a full-time registered dietitian or certified dietary manager with appropriate competencies and skill sets to carry out food and nutrition services.
F 803: The facility failed to follow menus prepared by the registered dietitian, substituting goulash for fish without prior approval.
F 804: The facility failed to serve food that was palatable and at a safe and appetizing temperature to residents on the 400 hallway, serving food below 135°F and leaving uncovered plates at unoccupied seats.
F 812: The facility failed to store food in refrigerators and freezers in the main kitchen according to professional food safety standards, including unlabeled and improperly stored raw and prepared foods.
F 880: The facility failed to maintain infection control practices by carrying unbagged soiled linens against staff clothing, placing clean linens on the floor during bed changes, and failing to change gloves during incontinence care.
F 921: The facility failed to provide a sanitary and comfortable environment in the 400 hallway dining room, including heavily stained chairs and a large fish tank with murky, malodorous water.
Report Facts
Residents in sample: 8
Residents census: 84
Clonidine dose error: 8
Temperature of fried potatoes: 122.9
Temperature of pureed vegetables: 130.4
Pressure ulcer size: 8.3
Pressure ulcer size: 7.2
Pressure ulcer size: 7
Pressure ulcer size: 6
Pressure ulcer size: 4.5
Pressure ulcer size: 5.2
Pressure ulcer size: 4.2
Pressure ulcer size: 2.3
Blood sugar: 59
Medication error dose: 0.8
Medication error dose: 0.1
Fall dates: 3
Fall dates: 2
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Licensed Nurse | Administered 8 times the ordered dose of Clonidine to resident #2 |
| Administrative Nurse B | Administrative Nurse | Reported expectations for care and confirmed medication and pain management issues |
| Dietary Manager L | Dietary Manager | Reported menu changes and food temperature issues |
| Direct Care Staff E | Direct Care Staff | Involved in transfer and incontinence care of resident #1 with pain complaints |
| Direct Care Staff J | Direct Care Staff | Reported staffing shortages and care challenges |
| Licensed Nurse K | Licensed Nurse | Intervened during resident #1's care in lift |
| Mid-Level Practitioner H | Physician Extender | Ordered Clonidine and commented on resident #1's transfer pain |
| Staff B | Administrative Nursing Staff | Administered insulin to wrong resident #5 |
| Physician N | Physician | Commented on fall causes for resident #3 |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Jul 12, 2019
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation & Health Care Center in response to deficiencies identified during a survey conducted on July 12, 2019.
Findings
The Plan of Correction outlines corrective actions and systemic changes to address multiple deficiencies related to resident privacy, dignity, assistance with activities of daily living, pressure ulcer prevention, fall prevention, catheter care, pain management, staffing, nursing competencies, medication administration, dietary services, food safety, infection control, and environmental cleanliness. The facility commits to ongoing monitoring and education to ensure substantial compliance by July 31, 2019.
Deficiencies (15)
F557-D: Resident #1 was not provided privacy during peri-care with roommate present. Resident #5 was not provided dignity by changing soiled clothing and washing face after meals.
F677-D: Residents #1, #3, and #5 were not consistently provided necessary services including bathing, shaving, repositioning, and assistance with eating.
F686-G: Resident #1 was not receiving adequate care to prevent or heal pressure ulcers; Resident #5 was not repositioned timely to prevent pressure ulcers.
F689-G: Resident #3's fall was not properly assessed and fall prevention measures were inadequate; Resident #1's transfer reassessed with appropriate mechanical lift used.
F690-D: Resident #1 was not receiving catheter care to prevent infection following bowel incontinence.
F697-G: Resident #1's pain was not adequately assessed or managed.
F725-F: Facility did not provide sufficient nursing staff to meet residents' nursing care plans.
F726-F: Nurses were not competent in providing nursing services; mentor/trainers lacked evaluation on competency completion.
F760-G: Residents #2 and #5 did not consistently receive medications without significant errors.
F801-F: Dietary Manager lacked completed approved CDM course; dietary staff needed education on food storage, temperatures, and menu adherence.
F803-F: Facility did not consistently follow menus approved by registered dietician; food substitutions were not always approved.
F804-E: Food served on 400 hall was not always palatable or at safe, appetizing temperatures; staff lacked education on serving protocols.
F812-F: Food storage in refrigerators and freezers did not meet professional food safety standards; staff lacked education on labeling and dating.
F880-E: Facility did not provide care to prevent infection spread; staff lacked education on infection control and proper linen handling.
F921-E: Facility did not maintain sanitary environment in 400 hall dining room; chairs were unclean and fish tank was present.
Report Facts
Date of survey exit: Jul 12, 2019
Plan of Correction substantial compliance date: Jul 31, 2019
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 29, 2019
Visit Reason
An off-site survey was conducted to address a deficiency cited on 2019-01-14.
Findings
The deficiency cited on 2019-01-14 was placed into compliance effective 2019-01-21.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey exiting on January 14, 2019, for Meridian Rehabilitation & Health Care Center.
Findings
The facility had a deficiency related to the development and documentation of a left heel pressure ulcer in Resident #2. The Plan of Correction outlines staff education, systemic changes, and ongoing monitoring to ensure compliance and prevent future occurrences.
Deficiencies (1)
F686-D: Resident #2 developed a left heel pressure ulcer with treatment orders being followed. Clinical staff received education on weekly skin assessments, reporting skin issues, and pressure ulcer prevention. Facility-wide skin assessments found no new pressure ulcers. One-on-one education was provided to the nurse who failed to report the ulcer. Ongoing monitoring will occur through QAPI meetings and wound rounds.
Report Facts
Deficiency cited: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Jan 14, 2019
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigations (KS00136842, KS00136742, KS00136772, KS00136777, and KS00135368).
Complaint Details
The inspection findings represent the results of complaint investigations identified by multiple complaint numbers. The facility failed to document and treat a pressure ulcer on the left heel of resident #2, which was substantiated by observations and interviews.
Findings
The facility failed to monitor and document a left heel pressure ulcer for a cognitively impaired resident at risk for pressure ulcers. Staff were unaware of the untreated pressure ulcer covered with eschar until the surveyor's observation, and documentation and treatment orders were delayed.
Deficiencies (1)
CFR 483.25(b)(1)(i)(ii): The facility failed to monitor and document a left heel pressure ulcer for a cognitively impaired resident at risk for pressure ulcers. The ulcer was untreated and covered with eschar until discovered during the survey.
Report Facts
Resident census: 76
Residents reviewed for pressure ulcers: 3
Pressure ulcer size: 1.5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-09-20.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-10-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 20, 2018
Visit Reason
This Plan of Correction document responds to deficiencies identified during the survey conducted on September 20, 2018, outlining corrective actions and systemic changes to assure compliance with regulations.
Findings
The facility addressed multiple deficiencies related to resident privacy, transfer/discharge notifications, baseline and comprehensive care plans, behavior management, and infection control practices, with corrective actions and monitoring plans to achieve substantial compliance by October 19, 2018.
Deficiencies (6)
F550-D Resident privacy rights were not fully honored during intimate moments; corrective actions include allowing privacy in rooms with curtains and doors closed and staff education on resident rights.
F623-D Transfer/discharge notices were not consistently communicated to the State Long-Term Care Ombudsman; systemic changes include staff re-education and auditing of notices.
F655-D Baseline care plans were not consistently developed for new admissions; nursing staff will be educated and audits conducted to ensure individualized baseline care plans.
F656-D Care plans were not consistently updated to reflect all areas of resident care including psychotropic medications; systemic changes include education and regular audits of comprehensive care plans.
F740-D Physician notification and documentation related to resident behaviors were incomplete; nurses will be re-educated and documentation audited daily.
F880-E Glucose meters were not disinfected properly; staff will be trained on proper disinfection procedures and audits will be conducted regularly.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 20, 2018
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility is found to be in substantial compliance effective 2018-10-19.
Deficiencies (1)
The facility had an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 6
Date: Sep 20, 2018
Visit Reason
Recertification survey conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS), including complaint investigations and facility reported incidents.
Complaint Details
Complaints investigated in conjunction with the recertification survey included multiple complaint numbers and a facility reported incident. The investigation identified failures related to residents' rights and other regulatory requirements.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to honor residents' rights regarding consensual sexual activity, failure to notify the Ombudsman of resident transfers, incomplete baseline and comprehensive care plans, inadequate behavioral health services, and improper infection control practices related to disinfecting glucose meters.
Deficiencies (6)
F550 Resident Rights: The facility failed to honor residents' rights and support consensual sexual activity choices for two residents with dementia, resulting in inappropriate monitoring and interventions.
F623 Notice Requirements: The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident's transfer to another facility as required.
F655 Baseline Care Plan: The facility failed to develop an accurate baseline care plan for a resident, omitting urinary catheter and hospice care information.
F656 Comprehensive Care Plan: The facility failed to develop and implement comprehensive, person-centered care plans for two residents, omitting medication and behavioral health needs.
F740 Behavioral Health Services: The facility failed to provide appropriate behavioral health care and services for a resident with aggressive and combative behaviors, including failure to notify physicians of behavior changes.
F880 Infection Prevention & Control: The facility failed to properly disinfect multi-use blood glucose meters according to manufacturer and facility policy, increasing risk of cross contamination.
Report Facts
Sample Size: 18
Supplemental Sample: 10
Resident Census: 78
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A complaint survey was conducted on 06/8 and 06/11/2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found unsubstantiated with no noncompliance.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A complaint survey was conducted on June 8 and 11, 2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 8, 2018
Visit Reason
A complaint survey was conducted on June 8 and 11, 2018 for complaint #KS00130222.
Complaint Details
Complaint #KS00130222 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The complaints investigated were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2018
Visit Reason
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 6, 2018
Visit Reason
An off-site survey was conducted to review deficiencies cited on February 27, 2018, and verify their correction by the compliance date of March 16, 2018.
Findings
The deficiencies cited on February 27, 2018, were corrected as of the compliance date of March 16, 2018.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 5, 2018
Visit Reason
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for complaints #KS00128201, #KS00120881, and #KS127419.
Complaint Details
The allegations made in the complaints were not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Deficiencies (1)
A complaint survey was conducted on 2018-04-05 and 2018-04-09 for specified complaints. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Feb 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #125501 and #126601.
Complaint Details
The inspection findings represent the results of complaint investigations #125501 and #126601.
Findings
The facility failed to maintain a comfortable temperature in the therapy room for residents receiving therapy services and failed to provide routine monitoring and treatment of skin conditions for three sampled residents, resulting in inadequate care and documentation.
Deficiencies (2)
F 584: The facility failed to maintain the therapy room at a comfortable temperature, with observed temperatures as low as 51 degrees Fahrenheit, causing discomfort to residents and staff.
F 684: The facility failed to ensure routine monitoring and treatment of skin conditions for three residents, including lack of documentation and failure to provide physician-ordered treatments.
Report Facts
Residents receiving therapy: 44
Facility census: 92
Temperature readings: 51
Temperature readings: 60.1
Temperature readings: 64.1
Years heating unit malfunctioned: 2
Deficiency counts: 2
Residents sampled for skin conditions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse B | Licensed Nurse | Confirmed therapy room temperature issues and wore a coat during the inspection. |
| licensed nurse J | Licensed Nurse | Reported changing dressings for resident #1 and #3 and was interviewed regarding skin treatment. |
| licensed nurse H | Licensed Nurse | Reported changing dressings for resident #1 and was interviewed regarding skin treatment. |
| maintenance staff D | Maintenance Staff | Reported on HVAC issues and maintenance logs for therapy room heating unit. |
| therapy staff A | Therapy Staff | Reported therapy room temperature issues and working with residents in hallways due to cold. |
| therapy staff C | Therapy Staff | Reported therapy room temperature issues and working with residents in hallways due to cold. |
| therapy staff F | Therapy Staff | Reported therapy room temperature issues and thermostat readings. |
| therapy staff G | Therapy Staff | Reported therapy room temperature issues. |
| administrative nurse E | Administrative Nurse | Provided expectations for weekly skin checks and reviewed documentation. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 27, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 16, 2018.
Deficiencies (1)
The facility had an "E" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 27, 2018
Visit Reason
This Plan of Correction document responds to deficiencies identified during a complaint survey conducted on February 27, 2018, at Meridian Rehabilitation and Health Care Center.
Complaint Details
This Plan of Correction follows a complaint investigation survey conducted on 02/27/2018.
Findings
The facility addressed issues related to maintaining therapy room temperature and proper documentation of treatment orders and skin assessments. Corrective actions include education, audits, and preventative maintenance scheduling to ensure compliance.
Deficiencies (2)
F584: The facility is maintaining the therapy room at a comfortable temperature for residents who receive therapy services. The HVAC system is functioning properly.
F684: Resident treatment orders have been audited to ensure attachment to the TAR and skin assessments updated to reflect skin alterations. Licensed nurses will be reeducated on weekly skin assessment policies.
Report Facts
Skin assessments audited weekly: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Submitted the Plan of Correction document. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 4, 2018
Visit Reason
An off-site survey was conducted to review deficiencies cited on November 22, 2017, with corrections verified as of December 8, 2017.
Findings
The deficiencies cited in the prior survey were corrected by the compliance date. No new deficiencies are detailed in this report.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Nov 22, 2017
Visit Reason
Complaint investigation #KS00122834 regarding allegations of abuse, neglect, and exploitation involving residents in the special care unit.
Complaint Details
Complaint investigation #KS00122834 substantiated failure to protect residents from abuse and failure to provide sufficient staffing to monitor residents in the special care unit.
Findings
The facility failed to protect residents in the special care unit from unwanted inappropriate personal contact and failed to provide sufficient staffing to monitor residents and prevent inappropriate behaviors and roaming into opposite gender rooms.
Deficiencies (2)
483.12(a)(3)(4)(c)(1)-(4) The facility failed to protect residents in the special care unit from unwanted inappropriate personal contact from residents #2 and #3, including sexual advances and kissing incidents.
483.35(a)(1)-(4) The facility failed to provide sufficient nursing staff to monitor 19 residents in the special care unit, resulting in residents roaming into opposite gender rooms and inappropriate touching.
Report Facts
Facility census: 86
Special care unit residents: 19
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 22, 2017
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey conducted on November 22, 2017, addressing compliance issues related to resident safety and care.
Findings
The facility identified issues related to resident privacy, unwanted sexual advances, and insufficient monitoring of residents on the special care unit. Interventions including staff training and increased monitoring were implemented to address these concerns.
Deficiencies (2)
F225: The facility will implement interventions to decrease unwanted sexual advances and protect residents on the special care unit from inappropriate contact. Staff have received dementia training and behavior management is monitored regularly.
F353: The facility will ensure sufficient staffing to monitor residents on the special care unit to prevent roaming and inappropriate touching. Staff received dementia training and a new special care unit manager was hired to assist with program management.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 22, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective December 8, 2017.
Deficiencies (1)
The facility had an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 19, 2017
Visit Reason
A revisit survey was conducted on 10/17/17, 10/18/17, and 10/19/17 to verify correction of all previous deficiencies cited on 9/12/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 4
Date: Sep 12, 2017
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigations related to resident care and safety.
Complaint Details
The inspection findings represent the results of complaint investigations #119979, #119989, #120169, #119270, and #120235.
Findings
The facility was found deficient in maintaining resident dignity related to catheter care, preventing and treating pressure ulcers, investigating falls and implementing fall prevention interventions, and developing nutritional interventions for residents at risk of inadequate nutrition or weight loss.
Deficiencies (4)
F241: The facility failed to maintain the catheter drainage bag in a dignity bag for 1 of 3 residents reviewed, resulting in the bag lying directly on the floor.
F314: The facility failed to reassess pressure ulcer risk after a significant change, develop interventions to prevent pressure ulcers, and promote healing for 1 resident who developed a deep tissue injury and a stage 2 pressure ulcer.
F323: The facility failed to thoroughly investigate the causal factors of a resident's fall and implement appropriate interventions to reduce further fall risk.
F325: The facility failed to develop nutritional interventions for a resident at risk for inadequate nutrition and/or weight loss despite documented decline and hospice admission.
Report Facts
Resident census: 84
Weight loss: 6
Fall risk score: 39
Pressure ulcer measurements: 2
Deep tissue injury measurements: 7
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 12, 2017
Visit Reason
This Plan of Correction document responds to deficiencies identified during a survey exiting on September 12, 2017, for Meridian Rehabilitation and Health Care Center. The purpose is to outline corrective actions taken to address cited deficiencies and assure compliance with regulations.
Findings
The facility identified deficiencies related to catheter dignity bag placement, pressure ulcer risk assessment and prevention, fall root cause analysis, and nutritional interventions for residents. Corrective actions include staff education, audits, and ongoing monitoring to ensure compliance and resident safety.
Deficiencies (4)
F241-D: Resident #1 catheter is in a dignity bag. All residents with foley catheters have the potential to be affected. Nursing staff educated on dignity and proper placement of foley catheter bags. Audits will monitor compliance.
F314-G: Resident #2 skin risk assessment updated with interventions to prevent pressure ulcers and promote healing. Staff educated on Pressure Ulcer Protocol and audits conducted to ensure interventions and care plans are in place.
F323-D: Root Cause Analysis completed for Resident #1's fall. Nursing administration educated on root cause analysis and will review occurrence reports regularly to ensure appropriate interventions and minimize fall risk.
F325-D: Resident #2 received nutritional interventions for inadequate nutrition and/or weight loss. Staff educated and audits conducted to ensure care plans address impaired nutrition and weight loss.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 12, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (1)
F314 Pressure Ulcers: The facility is noncompliant with requirements to prevent avoidable pressure ulcers and to provide appropriate care to prevent increased complexity of existing ulcers.
Report Facts
Denial of payment effective date: Oct 3, 2017
Compliance deadline: Mar 12, 2018
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon Hiebert | Administrator | Named as facility administrator in the report. |
| Caryl Gill | Complaint Coordinator | Named as complaint coordinator in relation to enforcement and dispute resolution. |
| Lisa Hauptman | CMS Contact | Contact person for questions regarding the matter. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 31, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 31, 2017
Visit Reason
This visit was a follow-up to verify correction of previously cited deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The report documents that all previously reported deficiencies identified by regulation numbers 26-40-303 (b)(i)(ii)(iii)(iv)(c), 26-40-305 (3), and 26-40-305 (i)(1)(2)(3) have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Jul 31, 2017
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation & Health Care Center outlining corrective actions and interventions to address previously identified deficiencies and ensure compliance with regulations.
Findings
The facility addressed multiple deficiencies including resident rights to bathing preferences, reasonable accommodations, significant change assessments, medication storage, infection control, emergency call button accessibility, and maintenance issues such as non-operable whirlpool tubs and improper electrical outlets. Staff education, audits, and quality assurance meetings were implemented to maintain compliance.
Deficiencies (14)
F242-D Residents have the right to choose a bath schedule of his/her choice. Resident #12's preference was interviewed and care plans updated accordingly.
F246-D Resident #58's wheelchair was moved to accommodate Resident #12's needs. Staff educated on reasonable accommodations in shared rooms.
F274-D The policy for Significant Change was reviewed and education provided. Significant change assessments completed for Resident #12.
F309-D Resident #60's fluid restriction order was reviewed and communicated. Staff educated on fluid restriction monitoring and documentation.
F329-D Resident #11's physician was notified of elevated blood glucose readings. Staff educated on notification policies and monitoring.
F334-E Pneumococcal vaccine administration and refusals were documented and staff educated on consent and refusal procedures.
F364-E Dietary staff received education on puree food preparation and audits to ensure proper procedures.
F371-F Thicken liquids, health shakes, and cheddar cheese not labeled or dated were removed. Staff educated on proper labeling and dating.
F428-D Physician notification procedures for blood glucose monitoring were reviewed and staff educated. Monitoring and audits implemented.
F431-E Medication storage deficiencies were corrected. Staff educated on labeling, dating, expiration, and temperature monitoring.
F441-F Monthly QA Infection Control reports were completed and staff educated on infection control policies and procedures.
S1166-E Facility failed to have emergency call buttons or pull cords within reach at whirlpool tubs and toilets. Corrections made and maintenance educated.
S1364-F Facility failed to ensure hydrocollator was plugged into a GFCI outlet. Corrected and staff educated on requirements.
S1372-F Facility had two non-operable whirlpool tubs and corroded hot water tank piping. Repairs ordered and maintenance educated.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 3, 2017
Visit Reason
The visit was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective July 31, 2017.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 3, 2017
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and posed no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the plan of correction acceptance letter. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 11
Date: Jul 3, 2017
Visit Reason
Health Resurvey and Complaint Investigation conducted to assess compliance with resident rights, care, infection control, medication management, and facility policies.
Complaint Details
The inspection was triggered by complaints regarding resident care, infection control, medication management, and facility compliance with regulations.
Findings
The facility was found deficient in multiple areas including failure to follow resident bathing preferences, reasonable accommodation of resident needs, timely completion of significant change assessments, monitoring and following fluid restrictions, notification of physician for abnormal blood sugars, influenza and pneumococcal immunizations, preparation of pureed foods, sanitary food storage, medication storage and disposal, and infection control practices.
Deficiencies (11)
F242 - The facility failed to follow the bathing preferences of resident #12 who requested daily showers but received only two per week.
F246 - The facility failed to reasonably accommodate resident #12's needs by improperly placing resident #58's wheelchair blocking access to the hand sink.
F274 - The facility failed to complete a significant change in status MDS within 14 days for resident #12 after a decline in activities of daily living.
F309 - The facility failed to monitor and follow a fluid restriction of 960 ml per day for resident #60 receiving dialysis.
F329 - The facility failed to notify the physician of blood sugar levels above set parameters for resident #11, resulting in lack of appropriate treatment adjustments.
F334 - The facility failed to ensure residents #84 and #70 received education and were offered influenza immunizations, and failed to offer or document pneumococcal immunizations for residents #12, #84, #27, and #70.
F364 - The facility failed to prepare pureed turkey according to dietician-approved recipes, compromising nutritive value for 12 residents receiving pureed diets.
F371 - The facility failed to store and distribute food under sanitary conditions by not discarding expired food and failing to date open food items in refrigerators.
F428 - The facility failed to ensure the consulting pharmacist identified and reported drug irregularities related to nursing staff's failure to notify physicians of abnormal blood sugars for resident #11.
F431 - The facility failed to monitor medication storage refrigerator temperatures, medication expiration dates, and proper disposal of unused medications, risking resident safety.
F441 - The facility failed to implement an effective infection prevention and control program including tracking and trending infections, proper sanitization of equipment, and adherence to disinfectant wet times, increasing risk of infection spread.
Report Facts
Residents in sample: 28
Fluid restriction: 960
Blood sugar readings: 456
Blood sugar readings: 467
Blood sugar readings: 396
Pureed diet residents: 12
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nurse | Reported expectations for bathing preferences, fluid restrictions, immunizations, infection control, and medication monitoring |
| Licensed nurse C | Licensed Nurse | Reported resident #118 diagnosis and infection control procedures |
| Dietary staff N | Dietary Staff | Observed preparing pureed foods incorrectly |
| Dietary consultant P | Dietary Consultant | Directed staff on pureed food preparation |
| Consulting pharmacist Q | Consulting Pharmacist | Reported reviewing blood sugars but did not identify irregularities |
| Housekeeping staff HH | Housekeeping Staff | Observed cleaning resident room with improper disinfectant use |
| Housekeeping staff KK | Housekeeping Staff | Observed cleaning resident room with improper disinfectant use |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Jun 15, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were reviewed and marked as corrected with completion dates of 05/05/2017. The revisit confirms that corrective actions were accomplished.
Deficiencies (10)
Regulation 483.10(h)(1)(3)(i); 483.70(i)(2) deficiency was corrected as of 05/05/2017.
Regulation 483.10(e)(1), 483.12(a)(2) deficiency was corrected as of 05/05/2017.
Regulation 483.12(a)(3)(4)(c)(1)-(4) deficiency was corrected as of 05/05/2017.
Regulation 483.10(a)(1) deficiency was corrected as of 05/05/2017.
Regulation 483.24(c)(1) deficiency was corrected as of 05/05/2017.
Regulation 483.40(d) deficiency was corrected as of 05/05/2017.
Regulation 483.20(d); 483.21(b)(1) deficiency was corrected as of 05/05/2017.
Regulation 483.25(d)(1)(2)(n)(1)-(3) deficiency was corrected as of 05/05/2017.
Regulation 483.35(a)(1)-(4) deficiency was corrected as of 05/05/2017.
Regulation 483.80(a)(1)(2)(4)(e)(f) deficiency was corrected as of 05/05/2017.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 2017
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The report documents that previously cited deficiencies have been corrected, with at least one correction completed on 2017-05-05. No uncorrected deficiencies are indicated.
Deficiencies (1)
Regulation 28-39-160 deficiency was corrected as of 2017-05-05. No other deficiencies are listed as outstanding.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 15, 2017
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The report documents that previously cited deficiencies have been corrected as of the indicated dates. Only one specific deficiency with regulation number 28-39-160 is noted as corrected on 05/05/2017.
Deficiencies (1)
Regulation 28-39-160 deficiency was corrected as of 05/05/2017.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Apr 19, 2017
Visit Reason
This Plan of Correction document responds to deficiencies identified during a complaint survey conducted at Meridian Rehabilitation and Health Care Center on April 19, 2017.
Findings
The facility implemented corrective actions addressing issues such as resident wandering, restraint use, abuse prevention, resident dignity, activity programming, communication challenges, fall risk, incontinent care, and proper resident placement. Education and monitoring plans were established to ensure ongoing compliance and resident safety.
Deficiencies (12)
F0000: The facility asserts compliance with all corrections described in this Plan of Correction following the April 19, 2017 survey.
F164-E: Care plans for residents #5 and #20 were reviewed and updated to address wandering behaviors, including pharmacy and psychiatric consultations and staff education on supervision and privacy.
F221-D: Resident #3 no longer resides in the facility; assessments and care plans for resident #4 were updated regarding transfer, mobility, and restraint status with audits to ensure recliners are not used as restraints.
F225-F: Resident #6 no longer resides on the unit; staff were educated on abuse prevention policies including immediate reporting and investigation procedures.
F241-E: Staff were re-educated on protecting resident dignity, including grooming, appropriate clothing, and respectful communication, with ongoing compliance monitoring.
F248-E: Activity programs were reviewed and adjusted to meet individual resident preferences, with staff education and monitoring of activity engagement.
F250-D: Communication aids such as picture cards were provided to assist residents with communication challenges, with staff education and observation to ensure proper use.
F279-D: Audits and updates of care plans were conducted to ensure they reflect resident needs and preferences, especially after falls, with staff education on fall interventions and root cause analysis.
F323-G: Care plans for residents at risk of falls were reviewed and updated to ensure appropriate interventions are in place to minimize fall risk.
F353-E: Staff were educated on their responsibility to provide appropriate supervision and care to meet resident needs, with corrective actions and monitoring in place.
F441-E: Staff were educated on proper cleaning and infection control related to incontinent episodes, with observations and corrective actions to ensure compliance.
S0740-E: Physician orders for resident placement were audited and ensured at admission, with staff education and ongoing review for compliance with unit admission criteria.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Derousseau | Administrator | Administrator submitting the Plan of Correction and named in education and compliance oversight. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 10
Date: Apr 19, 2017
Visit Reason
Partial extended survey for complaint investigations related to privacy, restraints, abuse, infection control, falls, and care planning at Meridian Rehabilitation and Health Care Center.
Complaint Details
The complaint investigation was triggered by allegations of privacy violations, improper use of restraints, resident-to-resident abuse, inadequate infection control, falls, insufficient staffing, and deficient care planning at the facility.
Findings
The facility failed to ensure resident privacy and dignity, adequate supervision to prevent wandering and falls, proper infection control, accurate care plans, and sufficient staffing in the memory care unit. Resident-to-resident altercation was not properly investigated or reported. Falls were not adequately analyzed or prevented. Infection control practices were deficient, including failure to clean urine spills and change contaminated clothing. Activities were not provided as scheduled.
Deficiencies (10)
F164: Facility failed to ensure privacy for residents in the memory care unit by lack of supervision allowing residents #5 and #20 to wander into other resident rooms.
F221: Facility failed to ensure residents #3 and #4 were in the least restrictive environment and assessed for restraints; resident #3 was placed in a recliner with footrest elevated and unable to lower it independently; resident #4 was positioned in wheelchair wedged between wall and table restricting movement.
F225: Facility failed to thoroughly investigate and report a resident-to-resident altercation where resident #6 pushed resident #5 causing lacerations; investigation was delayed and incomplete, and interventions were insufficient to protect residents.
F241: Facility failed to ensure staff treated residents #3, #4, #5, and #20 with dignity; staff loudly announced resident incidents, failed to cover residents appropriately, and changed briefs in other residents' rooms.
F248: Facility failed to provide structured activities per schedule for residents in the memory care unit; residents were observed without engagement and staff were not present to assist with activities.
F250: Facility failed to provide medically related social services to residents #2 and #5 who had English as a second language; no translators or communication plans were in place to meet residents' language needs.
F279: Facility failed to develop and implement accurate, specific care plans for resident #6 including preferences for foods, beverages, and awakening times.
F323: Facility failed to ensure resident #4 received adequate supervision to prevent falls; resident sustained multiple falls including one with subdural hematoma requiring hospitalization; facility failed to identify causal factors and implement effective interventions for falls for residents #1, #2, and #4.
F353: Facility failed to provide sufficient nursing staff with appropriate skills to provide care, supervision, and activities in the memory care unit; staffing shortages contributed to lack of privacy, supervision, and fall prevention.
F441: Facility failed to maintain infection control in the memory care unit; urine spills were not promptly and properly cleaned, resident #5 wore urine-soaked socks into dining room, staff failed to clean chair after resident #11 sat bare bottomed, and resident #20's brief was changed in another resident's room without changing bedding.
Report Facts
Residents in memory care unit: 17
Resident #5 census: 84
Resident #5 skin tears: 4
Resident #4 staples: 5
Resident #4 subdural hematoma size: 2
Resident #4 falls: 7
Resident #2 falls: 11
Resident #6 BIMS score: 1
Resident #5 BIMS score: 1
Resident #1 BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct Care Staff | Mentioned in relation to wandering resident #5 and infection control issues |
| Staff E | Direct Care Staff | Mentioned in relation to infection control and resident care |
| Staff F | Direct Care Staff | Mentioned in relation to resident care and infection control |
| Staff A | Administrative Nursing Staff | Interviewed regarding care plan expectations, fall investigations, and infection control |
| Staff C | Administrative Nursing Staff | Interviewed regarding resident altercation investigation and care plan updates |
| Staff D | Social Services Staff | Interviewed regarding wandering residents and language barriers |
| Staff H | Licensed Nurse | Interviewed regarding resident falls and behaviors |
| Staff K | Licensed Nurse | Interviewed regarding fall prevention and resident supervision |
| Staff M | Licensed Nurse | Interviewed regarding resident falls and care plan updates |
| Staff Q | Direct Care Staff | Interviewed regarding resident fall prevention |
| Staff T | Direct Care Staff | Interviewed regarding staffing shortages in memory care unit |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 19, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at F225 (Restraints) and F323 at a level of actual harm that is not immediate jeopardy, resulting in substandard quality of care. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (2)
F225, Restraints: The facility was noncompliant with requirements related to the use of physical restraints, placing residents at risk for urinary incontinence, skin breakdown, accidents, increased agitation, and social isolation.
F323: Deficiency found at a level of actual harm that is not immediate jeopardy requiring corrections.
Report Facts
Denial of payment effective date: May 12, 2017
Compliance deadline: Oct 19, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the enforcement action and informal dispute resolution |
| Lisa Hauptman | CMS Regional Office Contact | Contact for questions regarding the matter by phone |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Dec 20, 2016
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a complaint survey conducted on December 20, 2016.
Findings
The facility addressed issues related to managing escalating resident behaviors, particularly sexual behaviors of resident #1, by implementing multidisciplinary interventions, staff in-services, and enhanced 24-hour report processes to identify and manage resident behaviors requiring intervention.
Deficiencies (4)
F250-D: The facility will provide medically related social services involvement to develop plans to address, manage, and when possible prevent escalating behaviors. The care plan for resident #1 was updated accordingly.
F250DX1: Certified and licensed nursing staff will be in-serviced immediately on their roles in the 24 hour report process, including documentation and identification of resident behaviors requiring interventions.
F280-D: The facility will provide individualized resident care plans updated with interventions to manage resident behaviors, including updates for resident #1 after collaboration with social services and nursing staff.
F280DX1: Certified and licensed nursing staff will be in-serviced on documenting resident behaviors and categorizing behaviors as 'behavior note' in the 24 hour report process, with ongoing review in weekly 'At Risk' meetings.
Report Facts
Date of survey exit: Dec 20, 2016
Plan of Correction completion date: Dec 20, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 20, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all cited deficiencies were corrected as of the revisit date. Each deficiency previously identified was marked as completed.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 8, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
A 'D' level deficiency was cited indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint survey (#109036) to investigate allegations of abuse and failure to provide medically related social services for a resident exhibiting escalating sexually inappropriate behaviors.
Complaint Details
The complaint survey (#109036) was triggered by allegations of abuse related to sexually inappropriate behaviors by resident #1 toward resident #2. The facility failed to involve medically related social services or update care plans to address these behaviors prior to a significant incident on 12/3/16.
Findings
The facility failed to ensure that one of two residents reviewed for abuse had medically related social service involvement to develop a plan to manage and prevent escalating sexual behaviors. Additionally, the facility failed to update individualized care plans with interventions to prevent behaviors and protect residents in the Memory Care Unit.
Deficiencies (2)
483.40(d) The facility failed to provide medically related social services to manage and prevent escalating sexual behaviors of a resident in the Memory Care Unit.
483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) The facility failed to ensure the resident's right to participate in care planning and failed to develop individualized care plans with interventions to manage escalating sexual behaviors.
Report Facts
Facility census: 84
Memory Care Unit residents: 17
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 4, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with deficiencies at an "F" level under the Life Safety Code, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 18, 2016
Visit Reason
This post-certification revisit was conducted to verify correction of previously identified deficiencies from the prior survey completed on 2015-12-31.
Findings
The revisit report confirms that the previously cited deficiency with regulation number 483.65 (ID Prefix F0441) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.65 deficiency identified by ID Prefix F0441 was corrected by the revisit date of 2016-01-18.
Report Facts
Deficiency correction date: Jan 18, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 5, 2016
Visit Reason
This Plan of Correction document addresses the corrective actions taken by Meridian Rehabilitation and Health Care Center following deficiencies identified during a survey conducted on January 5, 2016.
Findings
The facility committed to ensuring proper hand hygiene practices to reduce infection risk. Residents assessed showed no signs of infection, and ongoing monitoring and staff in-service training on infection control are planned to maintain compliance.
Deficiencies (1)
F441-E: The facility will ensure staff uses proper hand hygiene practices to reduce the risk of infection and cross contamination for all residents. Infection rates and control measures will be monitored regularly with staff training and audits conducted by nursing leadership.
Report Facts
Date of survey exit: Jan 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Jan 5, 2016
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers (#5347, #4904, #4909, #4844, #4875, #4796, and #4814).
Complaint Details
The findings represent the results of complaint investigations for multiple complaint numbers as listed in the report.
Findings
The facility failed to ensure proper hand hygiene by direct care staff during incontinent care, placing incontinent residents at risk for cross contamination and infection spread.
Deficiencies (1)
483.65 Infection Control: The facility failed to ensure three of five direct care staff washed their hands after each direct resident contact during incontinent care, risking cross contamination among 45 incontinent residents.
Report Facts
Facility census: 85
Incontinent residents: 45
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 31, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective January 18, 2016.
Deficiencies (1)
A 'D' level deficiency was cited indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 7, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All deficiencies previously cited were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates of 11/07/2015.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 8, 2015
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding the plan of correction and compliance status. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 10
Date: Oct 8, 2015
Visit Reason
The inspection was a health resurvey and complaint investigation triggered by complaint #79684.
Complaint Details
Complaint #79684 triggered the health resurvey inspection.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during dining, failure to honor resident bathing preferences, failure to complete significant change MDS assessments timely, failure to develop and revise comprehensive care plans, inadequate nursing staffing during dining, unsafe storage of chemicals, unsanitary food handling, and medication administration errors.
Deficiencies (10)
F241: The facility failed to promote dignity during dining in the secured dementia unit, with residents left unattended and exposed.
F242: The facility failed to honor resident bathing preferences for 2 residents and lacked a policy on resident choices.
F274: The facility failed to complete a significant change in status MDS within 14 days for resident #40 after a decline.
F279: The facility failed to develop comprehensive care plans reflecting bathing needs for resident #123 and dialysis care for resident #85.
F280: The facility failed to revise the care plan for resident #35 to include pressure ulcer care, repositioning, and use of pressure relief devices.
F309: The facility failed to provide necessary care for resident #85 including monitoring the dialysis shunt, post dialysis assessments, and dietary/fluid restrictions.
F323: The facility failed to secure hazardous chemicals in the beauty shop, making them accessible to cognitively impaired residents.
F353: The facility failed to provide adequate nursing staffing and supervision during dining in the secured dementia unit, leaving residents unattended and inadequately assisted.
F371: The facility failed to serve food under sanitary conditions, including use of pans with peeling non-stick coating and improper handling of dishware.
F425: The facility failed to ensure residents #33 and #120 received medications as ordered, including failure to notify physicians of unavailable medications and failure to administer Mirtazapine as ordered.
Report Facts
Residents in secured dementia unit: 19
Residents sampled: 21
Residents cognitively impaired and independently mobile: 12
Stage 3 pressure ulcer size: 2.5
Stage 3 pressure ulcer size: 1.5
Fluid restriction: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Administrative Nurse | Confirmed shower schedules should follow resident preferences and verified medication administration expectations. |
| Nurse G | Licensed Nurse | Reported resident #35's repositioning needs and resident #85's dialysis care. |
| Staff P | Direct Care Staff | Reported dialysis schedule and lack of knowledge about shunt precautions for resident #85. |
| Staff L | Direct Care Staff | Reported shower scheduling and lack of knowledge about dietary restrictions and shunt care for resident #85. |
| Staff AA | Direct Care Staff | Reported staffing shortages and supervision issues during dining in dementia unit. |
| Staff B | Certified Dietary Staff | Acknowledged pans with flaking non-stick coating should have been discarded. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Oct 7, 2015
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a survey conducted on October 7, 2015.
Findings
The facility identified multiple deficiencies related to resident dignity during dining, honoring resident bathing preferences, timely completion of significant change MDS assessments, comprehensive care planning including pressure ulcer prevention and dialysis care, environmental safety, adequate nursing staffing during dining, dietary sanitation, and pharmacy services. Corrective actions and staff in-services were implemented to address these issues.
Deficiencies (11)
F241-E: The facility failed to maintain and enhance each resident's dignity during dining. Plans of care were updated and staff were in-serviced to promote dignity during dining.
F242-D: The facility failed to honor resident choices regarding bathing. Resident bathing preferences were assessed and care plans updated accordingly.
F274-D: The facility failed to complete significant change MDS assessments within required timeframes. Processes and staff training were implemented to ensure timely completion.
F279-D: The facility failed to develop care plans addressing all resident needs, including ADLs and dialysis care. Care plans were reviewed and staff trained to improve accuracy.
F280-D: The facility failed to revise care plans to include pressure ulcer prevention and treatment. Care plans were updated and staff in-serviced on prevention protocols.
F309-D: The facility failed to ensure residents received necessary care to maintain highest practicable physical well-being, specifically related to dialysis care. Care plans were revised and staff trained.
F314-D: The facility failed to reposition residents as necessary to prevent pressure ulcers. Skin assessments and care plans were updated and staff trained on prevention.
F323-E: The facility failed to ensure the resident environment was free of accident hazards. Locks on hazardous chemical storage rooms were changed and staff trained on safety protocols.
F353-E: The facility failed to provide adequate nursing staff during dining in the dementia unit. Staffing patterns and supervision were reviewed and staff in-serviced.
F371-F: The facility failed to properly handle dishware and prepare food under sanitary conditions. Equipment was replaced, staff trained, and sanitation concerns addressed.
F425-D: The facility failed to ensure necessary pharmacy services for all residents. Medication ordering processes were reviewed and staff trained to prevent delays.
Report Facts
Date of survey exit: Oct 7, 2015
Plan of Correction completion date: Nov 7, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Named as submitting administrator and responsible for monitoring compliance |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 21, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies at Meridian Rehabilitation and Health Care Center were corrected.
Findings
All previously reported deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.20(d), 483.20(k)(1), 483.25(d), and 483.25(h) were corrected as of the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 22, 2015
Visit Reason
The visit was conducted to perform an Abbreviated survey on June 22, 2015, and a Life Safety Code survey on June 30, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The surveys found the most serious deficiencies to be 'F' level for the Life Safety Code survey and 'D' level for the Abbreviated survey. The facility submitted a plan of correction for the Abbreviated survey deficiencies and was found to be in substantial compliance based on the credible allegation of compliance and plan of correction.
Report Facts
Effective date for denial of payments: Sep 22, 2015
Provider agreement termination date: Dec 22, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter as Enforcement Coordinator for KDADS. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution for Life Safety Code Survey. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 22, 2015
Visit Reason
The visit was conducted to perform an Abbreviated survey on June 22, 2015, and a Life Safety Code survey on June 30, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The surveys found the most serious deficiencies to be 'F' level for the Life Safety Code survey and 'D' level for the Abbreviated survey. The facility submitted a plan of correction for the Abbreviated survey deficiencies, which was accepted, resulting in a finding of substantial compliance based on the credible allegation of compliance.
Report Facts
Denial of payments effective date: Sep 22, 2015
Provider agreement termination date: Dec 22, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter as Enforcement Coordinator for the Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution related to Life Safety Code survey deficiencies. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Jun 22, 2015
Visit Reason
Complaint investigations #87866 and #87957 were conducted to investigate allegations of failure to report an injury of unknown origin and deficiencies in care planning and fall prevention.
Complaint Details
The report is based on complaint investigations #87866 and #87957 concerning failure to report injuries and inadequate care planning and fall prevention.
Findings
The facility failed to report a serious injury of unknown origin timely, did not develop comprehensive care plans for toileting and skin care for residents #1, #2, and #3, failed to implement effective toileting programs to manage urinary incontinence, and did not thoroughly investigate falls or implement effective fall prevention interventions for resident #1.
Deficiencies (4)
F225: The facility failed to report an injury of unknown origin for resident #1 immediately as required.
F279: The facility failed to develop comprehensive care plans related to toileting and skin care for resident #1 and toileting for residents #2 and #3.
F315: The facility failed to provide treatment and services to maintain as much bladder function as possible for residents #1, #2, and #3 with urinary incontinence.
F323: The facility failed to thoroughly investigate each fall to determine the root cause for resident #1 and failed to develop and implement effective fall prevention interventions.
Report Facts
Facility census: 80
Fall incidents: 7
Bruise measurement: 9.5
Urinary incontinence episodes: 39
Urinary incontinence episodes: 24
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 22, 2015
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a survey exiting on June 22, 2015.
Findings
The Plan of Correction outlines corrective actions related to resident injuries, toileting and skin care needs, voiding monitoring, and fall management. The facility commits to ongoing monitoring and compliance by July 21, 2015.
Deficiencies (4)
F225-D: Resident #1's injury incident was investigated and reported to the State Agency. All residents potentially affected will be monitored and reported as required.
F279-D: Resident #1 discharged; Residents #2 and #3 will be assessed for toileting needs and care plans updated accordingly. All incontinent residents' care plans will be audited and revised as needed.
F315-D: Residents #2 and #3 will have a 72-hour voiding monitor and toileting program initiated if applicable. Newly admitted and changed residents will have bowel and bladder tracking completed with care plans updated.
F323-D: Resident #1 discharged. Root Cause Analysis will be completed on all falls with interventions initiated and care plans updated. Falls will be reviewed regularly and medication reviews completed for repeat fallers.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Wyckoff | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 16, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Report Facts
Deficiencies corrected: 7
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 16, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 have been corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of 08/15/2014, with corrective actions documented for each cited regulation.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified under regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 08/15/2014.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected on 08/15/2014.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
A first revisit was conducted to determine if the facility corrected deficiencies cited in the June 20, 2014 health survey related to compliance with Federal participation requirements for Medicare and Medicaid nursing homes.
Findings
The revisit found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
The revisit was conducted on August 18, 2014, to verify that the facility had achieved and maintained compliance with Federal requirements following the June 20, 2014 health survey.
Findings
The revisit found the most serious deficiencies to be widespread 'F' level deficiencies. The facility was determined not to be in substantial compliance, resulting in enforcement remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of the provider agreement.
Deficiencies (1)
The revisit identified widespread 'F' level deficiencies indicating serious noncompliance with Federal requirements for nursing homes.
Report Facts
Civil Money Penalty: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in the report. |
| Peter Mungai | Administrator | Facility administrator named in the report. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 08/15/2014. The revisit confirms completion of corrective actions for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 14
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
This is a revisit inspection to verify correction of previously reported deficiencies at Meridian Rehabilitation and Health Care Center.
Findings
The report confirms that the previously cited deficiency identified by regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 08/15/2014.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected by 08/15/2014.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Aug 18, 2014
Visit Reason
The inspection was a non-compliance revisit and complaint investigation triggered by allegations of abuse, neglect, and other regulatory concerns.
Complaint Details
The visit was complaint-related and included a non-compliance revisit. The complaint investigation focused on allegations of abuse, neglect, and mistreatment, including failure to report an injury of unknown origin.
Findings
The facility failed to immediately report an injury of unknown origin, did not complete a timely voiding diary for a resident, failed to maintain adequate staffing levels, lacked a registered nurse on duty for 8 consecutive hours on one day, failed to properly post daily nurse staffing information, and failed to label opened medication vials with opened or discard dates.
Deficiencies (7)
F225: The facility failed to immediately report an injury of unknown origin to the administrator and State agency for one resident.
F315: The facility failed to complete a voiding diary in a timely manner to assess a resident's voiding pattern after bladder assessment, delaying a toileting plan.
F353: The facility failed to maintain adequate staffing to meet residents' needs, including toileting, call light response, personal care, and restorative services.
F354: The facility failed to have a registered nurse on duty for 8 consecutive hours on 8/3/14.
F356: The facility failed to post daily nursing staffing information including total and actual hours worked by category in a clear and accessible manner.
F431: The facility failed to properly label opened insulin and Tuberculin vials with opened or discard dates in medication room refrigerators.
F520: The facility failed to develop and implement effective Quality Assessment and Assurance (QAA) plans to correct previously identified deficiencies.
Report Facts
Facility census: 74
Deficiencies cited: 7
Registered nurse hours missed: 8
Medication vial discard days - Novolog: 28
Medication vial discard days - Tuberculin: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff F | Interviewed regarding failure to immediately report injury of unknown origin. | |
| Administrative nursing staff B | Interviewed regarding staffing, medication labeling expectations, and QAA committee actions. | |
| Administrative nursing staff G | Interviewed regarding voiding diary and toileting plans. | |
| Consultant licensed nursing staff A | Interviewed regarding nursing staffing posting procedures. |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 18, 2014
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a survey exit on 08/18/2014.
Findings
The Plan of Correction addresses multiple deficiencies including investigation and reporting of abuse allegations, prevention of urinary tract infections, sufficient nursing staff coverage, RN staffing requirements, posting of nurse staffing information, proper labeling and storage of drugs and biologicals, and quality assurance committee meetings.
Deficiencies (7)
F225: Resident #104 had an injury of unknown origin reported and investigated. Staff were re-educated on abuse policy and monitoring procedures were implemented to ensure timely reporting and investigation of abuse allegations.
F315: A 72-hour voiding pattern assessment and toileting program will be initiated to prevent urinary tract infections for incontinent and partially incontinent residents.
F353: The facility will maintain sufficient 24-hour nursing staff per care plans and address staffing concerns through ongoing monitoring and recruitment efforts.
F354: The facility will ensure a registered nurse is present for 8 consecutive hours daily per CMS guidelines, with daily monitoring and backup plans for call-ins.
F356: Nurse staffing information will be posted daily using a new form showing actual hours, with daily compliance monitoring.
F431: Opened medication vials without proper labeling were discarded. All nurses will be re-educated on labeling requirements and medication storage will be monitored regularly.
F520: Quality Assurance Sub-Committees will continue weekly and monthly meetings with documented attendance and action plan reviews to ensure compliance and address deficiencies.
Report Facts
Completion date: Sep 16, 2014
Incident report date: Jul 28, 2014
Survey exit date: Aug 18, 2014
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
A first revisit was conducted on August 18, 2014, for the June 20, 2014 health survey to determine if the facility was in compliance with Federal participation requirements for nursing homes under Medicare and Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 18, 2014
Visit Reason
The revisit was conducted on August 18, 2014, to verify that the facility had achieved and maintained compliance with Federal requirements following a June 20, 2014 health survey.
Findings
The revisit found the most serious deficiencies to be widespread 'F' level deficiencies. The facility was determined not to be in substantial compliance, resulting in enforcement remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of the provider agreement.
Report Facts
Effective date of denial of payment: Sep 20, 2014
Recommended termination date: Dec 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in the report |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 6, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was found to have 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jun 20, 2014
Visit Reason
This document is a Plan of Correction submitted by Meridian Rehabilitation and Health Care Center in response to deficiencies identified during a survey that exited on June 20, 2014.
Findings
The Plan of Correction outlines corrective actions taken and planned to address multiple deficiencies related to facility management of personal funds, conveyance of personal funds upon death, grievance resolution, resident care plans, housekeeping, nursing staff adequacy, medication management, and facility maintenance. The facility asserts substantial compliance and describes ongoing monitoring and auditing processes.
Deficiencies (19)
F159: Facility management of personal funds: Resident #16 had notice sent to responsible family member about account balance. Monthly audits of residents' accounts will be conducted.
F160: Conveyance of personal funds upon death: Funds of residents #97 and #15 were conveyed after passing. Monthly audits will ensure compliance with conveyance policy.
F166: Right to prompt efforts to resolve grievances: Grievances including staffing concerns will be addressed by Administrator with assistance from Regional Director and Nurse. Additional staff hiring underway.
F225: Investigate/report allegations: Resident #18 interviewed with no concerns. Staff inserviced on abuse and neglect reporting procedures.
F242: Self-determination - Right to make choices: Resident #67's care plan revised to reflect bathing choice. All residents' care plans will be updated accordingly.
F247: Right to notice before room/roommate change: All residents will be notified of room/roommate changes. Social Services Director inserviced on policy.
F253: Housekeeping and maintenance: Repairs planned for rooms with scuff marks, discolorations, and chipped paint. Ongoing room remodel project.
F272: Comprehensive assessments: Residents #32, #84, #81, #7, #74, and #76 will have care plans revised. MDS staff trained on assessment process.
F279: Develop comprehensive care plans: Resident #72's care plan developed using comprehensive assessment results. Audits planned for all care plans.
F280: Right to participate in planning care: Resident #40's care plan revised to reflect fall interventions. DON to inservice nurses on care plan updates.
F312: ADL care provided for dependent residents: Resident #72's nail care plan revised. Activity staff to provide weekly nail care with monitoring.
F315: No catheter, prevent UTI, restore bladder: Resident #8 will have bowel and bladder voiding pattern established. Audits planned for incontinent residents.
F329: Drug regimen free from unnecessary drugs: Resident #31's medications reviewed by Pharmacy Consultant. Black box warnings added to care plans.
F353: Sufficient 24 hour nursing staff per care plans: Residents #72 and #8 receiving needed care. Medical recruiter hired to address staffing needs.
F356: Posted nurse staffing information: Nurse staffing posting for 6/17/14 was late. Staff Development Coordinator and weekend managers to be reeducated.
F371: Food procure, store/prepare/serve - Sanitary: Facility to continue serving food under sanitary conditions. Staff inserviced on food handling and hairnet use.
F428: Drug regimen review, report irregular, act on: Resident #31's medications reviewed. 100% audits of physician orders and medication records for black box warnings.
F431: Drug records, label, store drugs, and biologicals: Expired insulin pens and medications discarded. Staff inserviced on storage and expiration policies.
FS1354: Heating Ventilation, and AC: Ventilation repaired in beauty shop and facility. Maintenance Director to monitor ventilation 5 days/week for 6 weeks.
Report Facts
Completion date: Jul 20, 2014
Audit frequency: 100
Staff interviews: 3
Audit sample size: 5
Audit sample size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PETERMUNGAI | Administrator | Administrator responsible for monitoring compliance and named in multiple corrective actions |
| IRINASTRAKHOVA | Modified Plan of Correction document | |
| DON | Director of Nursing | Named in medication review, care plan audits, and staffing monitoring |
| Business Office Manager | Responsible for auditing residents' personal funds and conveyance upon death | |
| Regional Nurse | Assists Administrator with grievance resolution and weekly review of grievances | |
| Social Services Director | Inserviced on room/roommate change policy | |
| Maintenance Director | Monitors facility ventilation and maintenance compliance | |
| Dietary Manager | Monitors food handling and sanitary conditions | |
| Staff Development Coordinator | Reeducated on nurse staffing posting |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 20, 2014
Visit Reason
A health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an "F" level. As a result, enforcement remedies including denial of payment for new Medicare admissions were imposed effective September 20, 2014.
Report Facts
Enforcement effective date: Sep 20, 2014
Termination recommendation date: Dec 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jun 20, 2014
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level. As a result, enforcement remedies including denial of payment for new Medicare admissions were imposed effective September 20, 2014.
Report Facts
Enforcement effective date: Sep 20, 2014
Termination recommendation date: Dec 20, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Census: 79
Deficiencies: 17
Date: Jun 20, 2014
Visit Reason
Health resurvey and investigation of multiple complaints including personal funds management, grievance resolution, staffing concerns, abuse investigations, care planning, and medication management.
Complaint Details
Multiple complaints investigated including personal funds mismanagement, staffing shortages, abuse allegations, care planning deficiencies, and medication management issues.
Findings
The facility had multiple deficiencies including failure to notify residents about personal funds limits, delayed dispersal of resident funds after death, inadequate response to staffing concerns, failure to investigate and report resident abuse, failure to honor resident bathing preferences, failure to notify residents of roommate changes, inadequate maintenance and housekeeping, incomplete individualized care area assessments and care plans, failure to revise care plans after falls, inadequate nail care, failure to provide appropriate incontinence care, failure to monitor medications with black box warnings, insufficient nursing staffing, failure to post accurate daily nurse staffing information, failure to serve food under sanitary conditions, and improper labeling and disposal of insulin pens.
Deficiencies (17)
483.10(c)(2)-(5) The facility failed to notify a Medicaid resident when personal funds balance reached $200 less than the SSI limit and failed to notify quarterly thereafter.
483.10(c)(6) The facility failed to disperse resident funds within 30 days after death for 3 residents reviewed.
483.10(f)(2) The facility failed to respond and resolve repeated resident concerns about insufficient nursing staff to meet care needs.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) The facility failed to immediately report, investigate, and submit results of a resident-to-resident abuse incident within 5 working days.
483.15(b) The facility failed to offer and honor a resident's choice for bathing due to non-functioning bathtubs.
483.15(e)(2) The facility failed to provide proper notification prior to a roommate change for one resident.
483.15(h)(2) The facility failed to ensure proper preventative maintenance for multiple areas including walls, floors, and plumbing fixtures.
483.20(b)(1) The facility failed to complete individualized care area assessments (CAAs) with underlying causes, contributing factors, and risk factors for multiple residents.
483.20(d), 483.10(k)(2) The facility failed to use comprehensive assessment results to develop individualized care plans related to nail care for one resident.
483.20(d)(3), 483.10(k)(2) The facility failed to revise care plans for two residents to include interventions to prevent further falls after incidents.
483.25(a)(3) The facility failed to provide necessary nail care to maintain good grooming and personal hygiene for one resident.
483.25(d) The facility failed to provide appropriate treatment and services including individualized toileting program to restore bladder function for one resident.
483.25(l) The facility failed to ensure one resident was free of unnecessary drugs by not monitoring black box warnings for serious adverse side effects.
483.30(a) The facility failed to provide sufficient nursing staff to meet residents' needs as evidenced by repeated resident complaints and staff interviews.
483.30(e) The facility failed to post daily nurse staffing information including census and total hours worked by staff at the beginning of each shift.
483.35(i) The facility failed to serve food under sanitary conditions when staff did not restrain or cover hair while serving food in 2 of 3 dining rooms.
483.60(c) The facility failed to ensure insulin pens were properly labeled with opened dates and discarded within 28 days of opening as per manufacturer recommendations.
Report Facts
Residents reviewed for personal funds: 5
Residents reviewed for conveyance of funds upon death: 3
Residents in sample: 22
Facility census: 79
Deficiency counts: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Administrative Staff | Named in personal funds notification deficiency |
| Staff A | Administrative Nursing Staff | Named in staffing and care plan deficiencies |
| Staff G | Licensed Nursing Staff | Named in staffing deficiency and fall prevention |
| Staff K | Licensed Nursing Staff | Named in staffing and care plan deficiencies |
| Staff L | Licensed Nursing Staff | Named in medication monitoring deficiency |
| Staff N | Direct Care Staff | Named in food service and staffing deficiencies |
| Staff V | Direct Care Staff | Named in food service deficiency |
| Staff Z | Licensed Nursing Staff | Named in insulin pen labeling deficiency |
| Consultant DD | Consultant Pharmacist | Named in medication monitoring deficiency |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 12, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously reported on the CMS-2567 have been corrected as of 04/12/2013, with corrections documented for multiple regulatory requirements.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Mar 14, 2013
Visit Reason
This document is a Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during a survey conducted on March 14, 2013.
Findings
The facility addressed multiple deficiencies related to resident care plans, treatment services, medication management, fall prevention, food safety, dental services, and drug storage. Corrective actions include staff re-education, audits, implementation of new software for care plans, and ongoing quality assurance monitoring.
Deficiencies (11)
F156 SS=D NOTICE OF RIGHTS, RULES, SERVICES, CHARGES. The facility re-educated staff on issuing Medicare liability notices and implemented a log to ensure timely issuance and signature collection.
F279 SS=D THE DEVELOPMENT OF COMPREHENSIVE CARE PLANS. The facility completed comprehensive care plans for residents and hired a new MDS coordinator to ensure timely, individualized care plans.
F311 SS=D TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS. Nursing staff were re-educated on timely bathing documentation and a full-time bath aide was hired to assist with resident baths.
F312 SS=D ADL CARE PROVIDED FOR DEPENDENT RESIDENTS. Staff were re-educated on timely personal hygiene services and walking rounds were implemented to ensure prompt incontinence care.
F318 SS=D INCREASE/PREVENT DECREASE IN RANGE OF MOTION. Resident #80 was re-evaluated and a restorative program developed; staff were re-educated on providing and documenting restorative services.
F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES. Resident #87's care plan was updated to prevent falls, including securing grab bars and physical therapy re-evaluation.
F329 SS=E UNNECESSARY DRUGS. The facility purchased software to aid care plan development for medications and re-educated staff on medication indications and monitoring.
F332 SS=D FREE OF MEDICATION ERROR RATES OF 5% OR MORE. A medication administration audit and staff proficiency checks were implemented to ensure proper medication scheduling and administration.
F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE-SANITARY. The sugar storage container was replaced and kitchen staff were re-educated on food safety and sanitation practices.
F412 SS=D ROUTINE/EMERGENCY DENTAL SERVICES IN NFS. The facility secured outside dental resources and implemented oral care assessments for residents.
F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS& BIOLOGICALS. Expired medications were removed and staff re-educated on medication storage and labeling; weekly audits were initiated.
Report Facts
Deficiencies cited: 11
Inspection Report
Census: 82
Deficiencies: 11
Date: Mar 14, 2013
Visit Reason
Health Resurvey and Complaint Investigation with multiple complaint numbers.
Complaint Details
The inspection included a complaint investigation with complaint numbers 62931, 62917, 63383, and 58483.
Findings
The facility had multiple deficiencies including failure to provide written notification of payment status changes, incomplete comprehensive care plans, inadequate treatment to maintain or improve ADLs, failure to prevent falls, improper medication management, unsanitary food storage and serving conditions, lack of routine dental services, and failure to properly manage drug records and expired medications.
Deficiencies (11)
F156: The facility failed to provide written notification of a change in payment status to the representative of resident #86 receiving skilled services.
F279: The facility failed to develop comprehensive care plans within 14 days of admission for residents #110 and #80, including lack of diagnosis for medications and no restorative plan for a contracted hand.
F311: The facility failed to ensure resident #87 received bathing on a regular basis and failed to revise plans to encourage bathing.
F312: The facility failed to provide timely personal hygiene care to resident #75 who required extensive assistance.
F318: The facility failed to provide restorative services to resident #80 to increase or maintain range of motion for a contracted left hand.
F323: The facility failed to implement interventions to prevent falls for resident #87, including failure to revise care plans after multiple falls and lack of safety devices.
F329: The facility failed to ensure adequate indications for use, monitoring, and follow-up of 'as needed' medications and failed to administer all ordered medications for multiple residents.
F332: The facility had a medication error rate of 11.53% due to failure to administer Klor-Con with food and failure to administer Nadolol and Spironolactone as ordered for resident #110.
F371: The facility failed to store and serve food under sanitary conditions and failed to maintain dining tables in sanitary condition in all dining rooms.
F412: The facility failed to obtain routine dental services for resident #6 with dental problems.
F431: The facility failed to label medication open dates and failed to remove expired medications from medication carts, exposing residents to expired drugs.
Report Facts
Facility census: 82
Medication error rate: 11.53
Number of residents sampled for care plans: 27
Number of residents sampled for ADL: 3
Number of residents sampled for falls: 5
Number of residents sampled for unnecessary medications: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Documented verbal notification to resident representative about payment status change. | |
| Licensed Staff Q | Confirmed lack of comprehensive care plan for resident #110. | |
| Licensed Staff J | Described medication administration and follow-up procedures. | |
| Administrative Staff C | Discussed medication issues, care plan expectations, and fall prevention. | |
| Consultant Pharmacist S | Provided expectations for medication diagnosis, follow-up, and black box warnings. | |
| Licensed Staff L | Administered medications and acknowledged care plan deficiencies. | |
| Direct Care Staff F | Reported resident did not receive exercises for contracted hand. | |
| Direct Care Staff G | Reported resident's refusal of care and fall prevention interventions. | |
| Dietary Staff Z | Confirmed unsanitary dining tables. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 21, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all deficiencies previously cited in the CMS-2567 Statement of Deficiencies have been corrected by 09/20/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 21, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.10(b)(2), 483.10(b)(11), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25 were corrected by 09/20/2012.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 18, 2012
Visit Reason
This is a follow-up revisit to verify correction of previously reported deficiencies at Meridian Nursing & Rehabilitation Center.
Findings
The report documents that deficiencies previously cited under regulations 26-40-303 (b)(c) and 26-40-305 (c)(1)(2) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-40-303 (b)(c): Previously cited deficiency was corrected by 07/18/2012.
Regulation 26-40-305 (c)(1)(2): Previously cited deficiency was corrected by 07/18/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 18, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the prior survey were corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 17
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 18, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies from the survey completed on 2012-05-25.
Findings
The report documents that previously reported deficiencies identified by regulation numbers 26-40-303 (b)(c) and 26-40-305 (c)(1)(2) were corrected as of the revisit date 2012-07-18.
Deficiencies (2)
Regulation 26-40-303 (b)(c): Previously cited deficiency has been corrected as of 07/18/2012.
Regulation 26-40-305 (c)(1)(2): Previously cited deficiency has been corrected as of 07/18/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 18, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jul 18, 2012
Visit Reason
This document is a Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during a survey conducted on July 18, 2012.
Findings
The facility implemented corrective actions including re-education of staff on medical record release, notification of significant changes, investigation of allegations, fall prevention, and pain management. The facility asserts substantial compliance and ongoing monitoring through quality assurance meetings.
Deficiencies (4)
F153 SS = D RIGHT TO ACCESS/PURCHASE COPIES OF MEDICAL RECORDS: Resident #1014 medical records were delivered late during the survey, and staff were re-educated on proper procedures for timely release of medical records.
F157 SS = D NOTIFICATION OF CHANGES (INJURY/DECLINE/ROOM ETC): Staff were re-educated on notification procedures for significant changes in resident status to ensure timely reporting to responsible parties and physicians.
F225 SS = D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS: The facility reviewed fall prevention and investigation procedures, ensuring thorough investigations and follow-up on falls with injury.
F309 SS = G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING: Nursing staff were re-educated on pain management and hospice criteria, with emphasis on comprehensive pain assessments following falls or significant changes in condition.
Report Facts
Date of survey: Jul 18, 2012
Plan of correction completion date: Jul 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Wasser | Director of Nursing | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jul 18, 2012
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Meridian Nursing & Rehabilitation Center, detailing regulatory deficiencies identified during a survey completed on July 18, 2012.
Findings
The facility failed to meet requirements related to residents' rights to access and purchase copies of records, notification of changes involving injury or decline, investigation and reporting of allegations involving mistreatment or abuse, and provision of care to maintain the highest practicable well-being.
Deficiencies (4)
483.10(b)(2) Right to access/purchase copies of records was not met as the resident or legal representative was not provided access to clinical records within 24 hours or allowed to purchase copies with proper notice.
483.10(b)(11) Notification of changes was not met as the facility failed to promptly inform the resident, physician, or legal representative of accidents or significant changes in the resident's condition.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) Investigation and reporting of allegations was not met as the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were reported and investigated timely.
483.25 Provision of care/services for highest well-being was not met as the facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being.
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 18
Date: May 25, 2012
Visit Reason
Annual survey and complaint investigations were conducted to assess compliance with regulatory requirements and quality of care.
Complaint Details
The inspection included complaint investigations #56526, #56934, and #55949.
Findings
The facility had multiple deficiencies including failure to notify family of significant changes, failure to maintain dignity in care, unresolved resident grievances, unclean environment, incomplete assessments, inadequate care plan revisions, insufficient hydration and nutrition management, unsafe equipment, non-functional call systems, and ineffective quality assurance processes.
Deficiencies (18)
F 157: The facility failed to promptly notify a resident's legal representative of a significant decline in oral intake for 1 of 3 sampled residents.
F 241: The facility failed to ensure staff treated residents with dignity, demonstrated by gruff and disrespectful communication to 3 residents.
F 244: The facility failed to listen and act upon resident council grievances regarding linens, ice water, staffing, call lights, trash removal, and food temperature.
F 252: The facility failed to maintain cleanliness of the Station II dining room cabinets, drawers, and countertops and failed to maintain window screens in 6 residents' rooms.
F 272: The facility failed to thoroughly assess a resident's potential for dehydration and failed to provide adequate hydration for a resident requiring thickened fluids.
F 274: The facility failed to complete a comprehensive assessment after a resident experienced severe weight loss and failed to revise care plans accordingly.
F 280: The facility failed to review and revise care plans to address significant changes for 4 residents, including weight loss and behavioral changes.
F 312: The facility failed to ensure a resident received necessary grooming, specifically fingernail care, and failed to document refusals or attempts between bath days.
F 314: The facility failed to prevent development of avoidable pressure ulcers and failed to promptly reapply dressings as ordered for 1 resident.
F 319: The facility failed to develop and implement individualized behavioral interventions for 2 residents with dementia and behavioral disturbances, and failed to address medication side effects.
F 323: The facility failed to maintain a safe environment by allowing a resident to access potentially dangerous areas, failed to safely transfer a resident using a mechanical lift, and failed to maintain safe water temperatures in the main dining room sink.
F 325: The facility failed to maintain nutritional status by not identifying and addressing significant weight loss, failing to provide ordered fortified diets and supplements, and failing to provide adequate hydration for residents requiring thickened liquids.
F 364: The facility failed to provide nutritionally equivalent meal substitutions, failed to maintain food at proper temperatures, and failed to prepare pureed diets according to recipes.
F 371: The facility failed to maintain sanitary food preparation and serving conditions, including failure to remove outdated food, inadequate sanitizer levels in dishwashing, unclean microwave, ineffective hair restraints, and unsanitary food handling practices.
F 441: The facility failed to prevent infection by improper glove use and hand hygiene during incontinence care and food service, and failed to properly clean and sanitize the shower room and shower chair between residents.
F 456: The facility failed to maintain mechanical lifts in safe operating condition, with broken shifter handles and unlocked legs, posing safety risks to residents.
F 463: The facility failed to maintain a functional resident call system in the Station II shower room, risking resident safety.
F 520: The facility failed to maintain an effective Quality Assessment and Assurance program to identify and correct deficiencies including weight loss, dehydration, broken equipment, glove use, cleanliness, pressure ulcers, care plan revisions, and resident grievances.
Report Facts
Facility census: 90
Resident sample size: 27
Residents attending resident council: 19
Residents attending resident council: 24
Residents in Station II dining room: 27
Residents using Station II shower room: 28
Residents using mechanical lifts: 14
Resident weight loss: 29
Resident weight loss percent: 15.9
Resident weight loss percent: 13
Resident fluid intake average: 1233
Resident fluid intake deficit: 267
Water temperature: 134.6
Water temperature: 133.7
Water temperature: 133.9
Temperature of chicken on steam table: 110
Temperature of chicken on steam table: 120
Temperature of baked potato on steam table: 150
Number of residents receiving pureed diets: 8
Number of residents receiving meals from dietary department: 87
Number of residents receiving baths in Station II shower room: 28
Number of residents using mechanical lifts: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care staff M | Reported resident #83 stopped eating and drinking before hospitalization | |
| Direct Care staff FF | Observed treating residents without dignity and reported resident #104 behaviors | |
| Licensed nursing staff I | Reported resident #83 stopped eating and pocketing food | |
| Administrative Nurse B | Provided multiple interviews about resident care and QAA program | |
| Dietary staff EE | Reported dietary practices and resident intake monitoring | |
| Maintenance staff T | Reported on mechanical lift maintenance and repairs | |
| Direct Care staff O | Observed unsafe mechanical lift use and resident care | |
| Consultant W | Dietitian involved in nutritional assessments and staff training | |
| Licensed nursing staff E | Reported resident #106 behaviors and medication concerns | |
| Social Service staff KK | Discussed resident behavioral interventions and HOPE program | |
| Licensed nursing staff GG | Observed resident feeding and food temperature concerns | |
| Direct Care staff AA | Observed failure to change gloves and hand hygiene during incontinence care |
Inspection Report
Plan of Correction
Deficiencies: 21
Date: May 25, 2012
Visit Reason
This document is a Plan of Correction submitted by Meridian Health Care and Rehabilitation Center in response to deficiencies identified during a survey conducted on May 25, 2012.
Findings
The facility identified multiple deficiencies related to resident care, dignity, safety, infection control, nutrition, hydration, medication management, and environmental safety. The Plan of Correction outlines corrective actions, staff re-education, and ongoing monitoring to achieve substantial compliance by June 22, 2012.
Deficiencies (21)
F157 SS D Notification of changes: The facility failed to properly notify responsible parties of significant changes such as weight loss or refusal to eat. A mandatory staff in-service and weekly interdisciplinary meetings were implemented to address this.
F241 SS D Dignity and respect of individuality: The facility did not consistently promote care that maintains resident dignity and respect. Staff were re-educated and routine rounds with resident interviews were instituted.
F244 SS E Listen/act on group grievance: The facility failed to timely address grievances and recommendations from residents and families. The administrator began attending resident council meetings and staff were re-educated on grievance procedures.
F252 SS E Safe, clean, comfortable, homelike environment: The facility did not maintain a consistently clean and homelike environment. Cleaning schedules and maintenance audits were established.
F272 SS D Comprehensive assessments: The facility failed to complete accurate assessments for residents at risk of dehydration or requiring thickened liquids. Mandatory in-service and reassessments were conducted.
F274 SS D Comprehensive assessments after significant change: The facility did not complete timely assessments after significant changes such as weight loss. Staff were re-educated and weekly interdisciplinary reviews were implemented.
F280 SS E Right to participate in planning care: The facility did not fully involve residents and responsible parties in care planning. Invitations and attendance documentation were instituted.
F312 SS D ADL care provided by dependent residents: The facility failed to ensure proper grooming and nail care for dependent residents. Staff in-service and weekly rounds were implemented.
F314 SS G Treatment services to prevent/heal pressure sores: The facility did not consistently apply dressings to wounds. Staff were re-educated and wound care audits were established.
F319 SS D Treatment/services for mental/psychosocial difficulties: The facility failed to adequately manage behavioral and dementia care. Individualized care plans and weekly evaluations were implemented.
F323 SS E Free of accident hazards/supervision/devices: The facility did not adequately secure hazardous areas and monitor residents. Locks and monitoring procedures were implemented.
F325 SS G Maintain nutritional status unless unavoidable: The facility failed to adequately address weight loss and nutritional needs. Dietician reviews, fortified food programs, and weekly weights were instituted.
F327 SS D Sufficient fluid to maintain hydration: The facility failed to ensure adequate hydration for residents at risk. Fluid intake monitoring and reassessments were implemented.
F329 SS D Drug regimen is free from unnecessary drugs: The facility failed to properly manage psychoactive medications. Re-evaluations and staff re-education were conducted.
F364 SS F Nutritive value/appearance palatable/prefer temp: The facility failed to consistently maintain food quality and temperature. Audits and staff education were implemented.
F371 SS F Food procure, store/prepare/serve under sanitary conditions: The facility failed to maintain proper food storage and sanitation. Daily audits and staff education were instituted.
F441 SS E Infection control, prevent spread of infection/linens: The facility failed to maintain proper handwashing and cleaning procedures. Staff re-education and competency evaluations were implemented.
F456 SS E Essential equipment, safe operating condition: The facility had mechanical lifts out of service. Repairs and rental equipment were used with scheduled maintenance.
F463 SS E Resident call system-rooms/toilet/bath: The facility failed to maintain call light systems in shower rooms. Repairs and monitoring were implemented.
S1176 SS E Door monitoring system: The facility failed to maintain alarms on exit doors. Alarms were reset and staff were in-serviced.
S1354 SS E Heating, ventilation, and A.C.: The facility failed to ensure proper ventilation in the beauty shop. Contractor work and monthly monitoring were instituted.
Report Facts
Date of survey exit: May 25, 2012
Plan of Correction completion date: Jun 22, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Lang | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087003 POC 1UES11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N087003.
Findings
No deficiencies or findings are listed in this Plan of Correction document. It serves as a placeholder or administrative record without substantive content.
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