The Meadows at Shannondell.

“The home's Berwyck B exit door was not unlocked and unobstructed.”

“The facility failed to report a choking incident requiring Heimlich maneuver and hospitalization, and delayed reporting of a fall with head injury requiring staples to the Department within 24 hours as required.”

“Resident records were left unlocked, unattended, and accessible, including electronic medication records with resident names and prescription information on a medication cart, and resident assessment plans and lab logs in a nursing office.”

“A resident toilet had feces smeared on the bottom and an accumulation of dust and dirt at the corner of the shower, indicating unsanitary conditions.”

“An active leak was observed in the walkway between the 5000 and 6000 buildings with water running down the wall and wet carpet, and a large brown stain was observed above the kitchen and dining area in Chatham C's pantry kitchen.”

“Approximately 1 inch of snow was accumulated on the path to the Avondale courtyard exit and approximately 2 inches of snow and ice was accumulated on the patio near the salon exit, creating hazardous conditions.”

“Laptop containing resident medication administration records was unlocked, unattended, and accessible on the medication cart located in the hallway in Chatman house at 9:44am.”

“Administrator does not maintain a list of staff persons who worked in the personal care units of the home.”

“Multiple sanitary condition violations observed: a bag filled with urine in a resident's bathroom sink at 9:46am; a resident sitting in a chair stained with dark brown substance at 10:07am; and a resident's bedroom with strong odor of feces at 11:27am.”

“Resident's bed blanket is stained with what appears to be urine.”

“Bedroom floor stained with a red substance reported as dried Jello.”

“According to multiple resident interviews, residents do not evacuate to a fire safe area during fire drills when the fire drill is not near their room.”

“Therapeutic Moisturizing Mineral Lotion and Calmoseptine Ointment were unlocked, unattended, and accessible in a resident's bedroom at 9:50am. A&D ointment was unlocked, unattended, and accessible in a resident's bathroom at 9:57am.”

“A loose pill was observed in the medication cart located in Chatham B at 10:29am and a blister pack for a resident was torn for pill slot 3 and remained in the medication cart.”

“Resident assignment sheets containing confidential information about showers and incontinence care were left unlocked, unattended, and accessible on a medication cart in a hallway.”

“The home failed to submit timely incident reports to the Department for three separate serious incidents. A resident was found on the bathroom floor at base of toilet with head trauma; another resident was found unresponsive and received chest thrusts before hospitalization and subsequent death; a third resident was found on the floor with bruising and skin tear, later hospitalized and deceased. While delayed reports were eventually submitted for the latter two incidents, no initial reports were submitted within 24 hours as required.”

“A resident requiring assistance with toileting and unable to ambulate independently with a history of falls had an unwitnessed fall and lay on the bathroom floor for an unidentified length of time in saturated incontinence briefs with a skin tear. There is no documentation that staff checked on the resident every two hours during the night shift as required by facility training.”

“A resident requiring assistance with toileting and unable to ambulate independently had an unwitnessed fall and lay on the bathroom floor for an unknown period in saturated incontinence briefs. Staff did not check on the resident every two hours as trained. Additionally, the resident's physician ordered a urine culture test but staff never obtained the urine sample. The resident was hospitalized with a low temperature and subsequently died of sepsis and other conditions.”

“A resident's medical evaluation did not include the medication regimen, contraindicated medications, or medication side effects as required.”

“A discontinued medication was found in the home's narcotics locked box and should have been removed from the facility.”

“Medication cart and narcotics box keys were left unattended on an open medication station drawer instead of being kept on the nurse's person. Additionally, controlled substance counts were performed by a single nurse instead of two licensed nurses counting together and signing to verify accuracy.”

“Resident records did not include a record of incident reports for individual residents as required.”

“During multiple shifts, insufficient staff certified in first aid, obstructed airway techniques, and CPR were present. With 141 residents in the home, only one or two certified staff were scheduled during evening and night shifts when at least three certified staff were required (one per 50 residents).”

“Medication carts were found unlocked, unattended, and accessible in the hallway and in front of bedrooms at multiple times (9:44 AM, 9:51 AM, and 10:01 AM). This is a repeat violation.”

“A resident's narcotic inventory log for a medication prescribed as one-half tablet twice daily as needed did not include the time the medication was removed, contrary to the home's narcotic policy requiring documentation of removal time in the narcotic bound book.”

“A resident prescribed insulin four times daily per sliding scale had glucometer readings on three occasions requiring insulin administration, but the number of units given was not recorded on the medication administration record.”

“A resident's medication administration record did not include the initials of the staff person who administered a PRN medication on two occasions (one at 9:12 AM and one at an unknown time). This is a repeat violation.”

“Medications were not stored properly in medication carts. Three loose white half pills were found in the Chatham A/B wing cart, one loose partial pill and one loose yellow tablet in the first floor Inn Side cart, an expired medication box was in the Inn 4th floor B wing cart, and multiple resident blister packs had punctured foil.”

“Medication administration records contained inaccurate documentation of glucose readings that did not match glucometer data, and required medications were not available in the home at the time of inspection.”

“A resident prescribed to have glucose checks three times daily (7:30am, 11:30am, 4:30pm) did not receive checks at 11:30am and 4:30pm because the glucometer was not available in the home.”

“The facility's current license was not posted in a conspicuous and public place on the 4th floor of the 5000 building.”

“Staff person A refused to provide Department agents immediate access to the lower level Secured Dementia Care Unit when they requested entry. Additionally, on 4/15/24, staff misrepresented that a specific staff person was not working when time cards showed they were present during the inspection, preventing the agent from conducting a required incident investigation interview.”

“Resident records, including reportables, care plan information, and medication information, were unlocked, unattended, and accessible in the second floor Assistant Director of Nursing office. Additionally, a direct care staff communication log was unlocked and accessible in the Chatham hallway, and resident records were unlocked and accessible in the Chatham C hallway.”

“The facility's current license was not posted in a conspicuous and public place on the 4th floor of the 5000 building.”

“Staff person A refused to provide Department agents immediate access to the lower level Secured Dementia Care Unit when they requested entry. Additionally, on 4/15/24, staff misrepresented that a specific staff person was not working when time cards showed they were present during the inspection, preventing the agent from conducting a required incident investigation interview.”

“Resident records, including reportables, care plan information, and medication information, were unlocked, unattended, and accessible in the second floor Assistant Director of Nursing office. Additionally, a direct care staff communication log was unlocked and accessible in the Chatham hallway, and resident records were unlocked and accessible in the Chatham C hallway.”

“Resident 1 did not receive required assistance with bilateral hearing aids before being transferred for breakfast, and call bell requests were not responded to in a timely manner. Resident 2 did not receive required assistance with cutting up foods and verbal prompting during meals. Resident 3's catheter bag was observed to be 3/4 full with a strong urine odor in the room, indicating it was not properly drained during the overnight shift as required.”

“Resident 1 did not receive required assistance with bilateral hearing aids before being transferred for breakfast, and call bell requests were not responded to in a timely manner. Resident 2 did not receive required assistance with cutting up foods and verbal prompting during meals. Resident 3's catheter bag was observed to be 3/4 full with a strong urine odor in the room, indicating it was not properly drained during the overnight shift as required.”

“Resident 1's medical evaluation indicated the resident could safely use and avoid poisonous materials, but the resident's RASP (Resident Assessment Summary Profile) indicated the resident is not safe around poisonous materials, creating a discrepancy in the medical evaluation documentation.”

“Staff person B placed their feet behind resident 1's wheelchair to prevent movement, and staff person C placed chairs behind resident 1's wheelchair to prevent movement, constituting manual restraints which are prohibited.”

“Resident 2's support plan was developed but the assessor did not sign and date the support plan as required.”

“The home failed to report an incident of neglect to the Department within 24 hours. Residents #1 and #2 did not receive timely assistance after calling for help, and the home was aware of this allegation but did not report it.”

“Residents were neglected when staff failed to provide timely assistance. Resident #1 waited an extended period after a fall before receiving assistance and sustained a skin tear. Resident #2 waited an extended period for a bed pan and became completely soaked through.”

“Staff Member B placed a cloth in the mouth of Resident #4 to prevent biting during a transfer, which constitutes an improper restraint.”

“The home failed to implement positive interventions to modify or eliminate biting behavior exhibited by Resident #4. Instead of using positive interventions, Staff Member B placed a cloth in Resident #4's mouth.”

“Staff Member B placed a cloth in the mouth of Resident #4 to prevent biting, which is a prohibited procedure.”

“The home failed to report an incident of neglect to the Department within 24 hours. Residents #1 and #2 did not receive timely assistance after calling for help, and the home was aware of this allegation but did not report it.”

“Residents were neglected when staff failed to provide timely assistance. Resident #1 waited an extended period after a fall before receiving assistance and sustained a skin tear. Resident #2 waited an extended period for a bed pan and became completely soaked through.”

“Staff Member B placed a cloth in the mouth of Resident #4 to prevent biting during a transfer, which constitutes an improper restraint.”

“The home failed to implement positive interventions to modify or eliminate biting behavior exhibited by Resident #4. Instead of using positive interventions, Staff Member B placed a cloth in Resident #4's mouth.”

“Staff Member B placed a cloth in the mouth of Resident #4 to prevent biting, which is a prohibited procedure.”