Brookdale Meadow Springs

Facility failed to maintain compliance with fire safety codes: wall/ceiling penetrations in various rooms, failing fire-rated caulk, cracks in cross-corridor and emergency exit doors, lack of kitchen suppression system inspection records, and lack of smoke alarm testing documentation.

Facility could not provide documentation for monthly testing of single station smoke alarms for the past twelve months.

Observed multiple wall and ceiling penetrations in the Dining Services office, Laundry room, Staff Lunch room, Electrical room, and Mechanical room. The fire caulk used for previous repairs was not fire-rated.

Cross corridor fire doors (Rooms 217 and 236) and emergency exit stairwell door (Room 209) have cracks in the upper portion.

Facility provided documentation for the second semi-annual inspection of the kitchen suppression system, but did not provide reports verifying no deficiencies or confirming that deficiencies were corrected.

Facility failed to ensure a national fingerprint background check was completed for 2 of 5 staff members.

Facility failed to maintain a valid two-year name and date of birth background check for 1 staff member.

Facility failed to submit a name and date of birth background check within one business day of hire for 1 staff member.

Facility failed to ensure caregivers completed specialty mental health and dementia training, and failed to ensure staff met long-term care worker training requirements.

Facility failed to ensure staff were screened for tuberculosis within three days of hire for 3 of 4 staff.

Facility failed to maintain a safe, sanitary and well-maintained environment. Observations included stained carpeting, soiled/malodorous laundry rooms, broken furniture/fixtures, lack of soap/paper towels, missing fire extinguisher glass, unclean food carts, dust-covered HVAC vents, and failure to provide weekly housekeeping and laundry services as care-planned.

The facility failed to ensure the negotiated service agreement was agreed to and signed by the resident or their representative for 1 former resident and 1 current resident.

Facility failed to ensure a safe medication system for 2 of 3 residents; residents experienced missed doses and delayed medication start times.

Failed to implement a safe system for nurse delegation; delegation forms were incomplete or missing tasks/instructions, and 90-day re-evaluations were not performed as required.

Failed to ensure two-year background check renewals were submitted timely for two staff members.

Failed to submit background check authorization within one business day for one staff member and failed to verify three positive references for two staff members.

Facility failed to ensure a national fingerprint background check result was pending for a provisionally hired staff member with unsupervised access to residents; the request had not been submitted for 134 days.

Facility failed to ensure TB screening within three days of hire for 4 of 4 staff hired since the last inspection.

Facility failed to maintain examination or vaccination records for pets residing at the facility.

Facility failed to inform residents in writing of services, activities, and rules at least once every 24 months for 2 of 2 residents reviewed.

Facility failed to provide and maintain intact window screens, with 38 damaged or missing screens found out of 123 total.

Facility failed to provide a safe/sanitary laundry environment; the second-floor laundry was inaccessible due to flooding, and the first-floor area was cluttered with soiled items.

Facility failed to provide a clean and well-maintained environment; common areas had stained carpets and furniture, peeling flooring, odors, and hall surfaces were heavily stained.

Incomplete quarterly assessments for residents.

Background checks not completed for Staff E and F.

Background checks not completed for Staff A and B.

TB testing not completed for Staff A, B, C, and D.

Pet records missing for Residents 1, 10, and 11.

Failure to provide 24-month notifications.

Screens missing or damaged.

Laundry room was dirty and in need of repairs.

Facility dirty, walls/doors damaged, gutter/roof issues, housekeeping not occurring.

Staff failed to complete required facility and two-hour orientation training before caring for residents.

Staff missing valid CPR/First Aid certifications.

Staff failed to complete 3-hour safety training.