Meridian Assisted Living Home

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established, documented, and implemented, which included the amount, type, and frequency of assisted living services provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan dated July 14, 2025, which indicated R1 received personal care services. R1’s service plan outlined assistance with dressing, Ted Hose, personal hygiene, and shaving; however, it did not specify the frequency with which these services were provided. 2. A review of R2's medical record revealed a current written service plan dated November 25, 2025, which indicated R2 received personal care services. R2's service plan outlined Ted Hose and personal hygiene; however, it did not specify the frequency with which these services were provided. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, that when initially developed, was signed and dated by the resident or the resident's representative, and the manager, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s medical record revealed a service plan dated July 14, 2025. However, the service plan was not signed and dated by the resident or the resident's representative. 2. A review of R2’s medical record revealed a current written service plan dated November 25, 2025, not signed and dated by the resident or the resident's representative. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on August 31, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officers observed the following: The front door was equipped with an alert; however, the alert was not functional at the time of inspection; The back door was equipped with an alert; however, the alert was turned off at the time of inspection; The back door key was stored within the lock at the time of inspection; and The exits from the facility were not monitored at the time of inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the following: In an unlocked kitchen cabinet, a bottle of “Polyethylene Glycol 3350.” In the facility’s unlocked garage, a bottle of “Equate Medicated Body Powder.” 2. A review of the facility's policies and procedures revealed a policy titled “MEDICATION SERVICES." The policy stated, “All residents medications will be handled according to the procedures outlined below 5. All resident medications brought to the facility will be received by the caregiver on duty. Medications will be locked in the medication storage area. 6. All resident medications must be secured in a locked storage area. 7. Residents that self-administer medication may keep medications in their bedroom... The medications are kept in a secure locked place.”  3. In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on August 31, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officers observed the following: R3’s unlocked bathroom cabinet contained a bottle of Equate Antiseptic Mouthwash, a tube of Chamosyn with Manuka Honey, In the facility’s unlocked garage a can of Lysol Disinfectant Spray, a can of Christy’s Red Hot Blue Glue PVC Pipe Cement, and a can of Emerald paint; and In the facility’s backyard, a bucket of ProMar Ceiling Paint, and a bag of Ironite Plus. 2. A review of the facility’s policies and procedures revealed a policy titled "Emergency, Safety, and Environmental Standards”. The policy stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner, for one of two residents reviewed. The deficient practice posed a risk as the Department was provided false and misleading information. Findings include: 1. Review of R2's medical record revealed a written service plan post dated to September 1, 2023. This service plan was signed by E1 and R2. 2. In an interview, E1 acknowledged R2's service plan was completed and post dated to September 1, 2023.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed two cabinets in the kitchen that held ten residents' medications unlocked. The cabinet doors had locking devices, however were not locked. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E1 and E2 acknowledged medications were stored unlocked. 4. This is a repeat deficiency from the compliance inspection conducted September 19, 2022.