The Meadows of Rockwell Retirement Center

The facility failed to maintain the physical environment standards regarding bathroom and toilet room requirements. Specifically, certain repairs to bathroom fixtures or components were required to meet state regulations for safety and accessibility.

The facility failed to meet specific requirements regarding the physical environment of bathrooms and toilet rooms. This includes standards for the number of hand lavatories and bathtubs relative to resident count, as well as requirements for hand grips and privacy partitions.

The facility failed to provide feeding assistance with dignity and respect for two residents. During meal observations, staff members were found standing while providing feeding assistance to residents, which does not meet the requirement for unhurried assistance that maintains resident dignity.

The facility failed to provide feeding assistance with dignity and respect for two residents. Specifically, staff members were observed standing while providing feeding assistance to residents during lunch and breakfast meals.

The facility failed to implement physician orders for continuous oxygen for a resident. Specifically, a resident ordered for 4L of continuous oxygen was not using portable oxygen when ambulating in hallways or the dining hall, and there was no documentation in the eMAR to confirm oxygen administration.

The facility failed to ensure physician orders for continuous oxygen were implemented for a resident. Specifically, there was no documentation of oxygen administration in the eMAR, and the resident was observed without oxygen while in common areas because a portable oxygen tank was not provided.

The facility failed to maintain clean flooring, requiring the removal of carpet in halls and corridors and the implementation of new cleaning schedules and training.

The facility failed to maintain adequate staffing levels to meet resident needs and ensure timely response to call lights and requests for assistance.

The facility failed to properly manage resident transportation and documentation of appointments, necessitating the hiring of a driver and new logging procedures.

The facility failed to ensure all resident orders were properly processed and followed through, requiring the implementation of a 'Bucket System' for order management.

The facility failed to maintain sanitary kitchen equipment and surfaces, specifically regarding steam pans, cutting boards, and water puddling issues.

The facility failed to maintain accurate and up-to-date dietary orders and therapeutic diet documentation for residents.

The facility failed to ensure the accuracy of FL2s and discharge summaries prior to admission, necessitating improved verification processes and provider communication.

The facility failed to ensure all medications were available on carts and that staff were properly trained on the six rights of medication administration.

The facility failed to ensure proper EMAR verification and medication ordering/reordering procedures among staff and management.

The facility failed to maintain a consistent system for medication ordering, requiring the implementation of a bucket order system to track orders from fax to EMAR.

The facility failed to maintain clean and well-repaired floors and carpeting. Observations revealed significant staining, black grime, and debris in the main hallway and across 16 resident rooms. In several instances, the carpeting was so severely soiled with unidentifiable substances that the original beige color was no longer visible.