Meadow Falls of Middletown

Based on record review and staff interview, the facility failed to ensure unlicensed caregivers were taught personal care techniques by a licensed nurse. This had the potential to affect all of the residents residing in the facility. The facility census was 46 residents.

Findings include:

Review of the personnel file for Caregiver (CG) #9 revealed a hire date of 07/03/25 with no record of training in personal care services taught by a licensed nurse.

Review of the personnel file for Caregiver (CG) #11 revealed a hire date of 06/05/25 with no record of training in personal care services taught by a licensed nurse.

Review of the personnel file for Caregiver (CG) #12 revealed a hire date of 05/15/24 with no record of training in personal care services taught by a licensed nurse.

Interview on 10/23/25 at 2:32 P.M. with the Business Office Manager (BOM) and the Executive Director (ED) confirmed CGs #9, #11, and #12 had not been trained in personal care services by a licensed nurse.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure documentation of medication administration was completed. This affected two (Residents #14 and #26) of five sampled residents. The facility census was 46 residents.

Findings include:

Review of the Medication Administration Record (MAR) for Resident #26 dated October 2025 revealed the resident was scheduled to receive the following medications during the evening med pass: Aricept, Pravachol, Seroquel. The MAR for Resident #26 was not signed off for the evening medication administration on 10/03/25 and 10/06/25.

Review of the progress notes for Resident #26 dated 10/03/25 and 10/06/25 revealed the notes did not include documentation of resident refusal of medication nor did they include a rationale regarding why the medications were not signed off in the MAR.

Review of the MAR for Resident #14 dated October 2025 revealed the resident was scheduled to receive the following medications during the evening med pass: Pravachol, multivitamin with minerals, vitamin E, Tylenol. The MAR for Resident #14 was not signed off for the evening medication administration on 10/03/25 and 10/12/25.

Review of the progress notes for Resident #14 dated 10/03/25 and 10/12/25 revealed the notes did not include documentation of resident refusal of medication nor did they include a rationale regarding why the medications were not signed off in the MAR.

Interview on 10/27/25 at 11:42 A.M. with the Health and Wellness Director (HWD) confirmed the MAR for Resident #26 did not include documentation of medication administration for the evening med passes 10/03/25 and 10/06/25. The HWD confirmed the MAR for Resident #14 did not include documentation of medication administration for the evening med passes on 10/03/25 and 10/12/25. The HWD confirmed the progress notes for Residents #26 and #14 did not include notations regarding why the medications weren't documented as administered..

Review of the facility policy titled Administering Medications revised 2021 revealed the nurse administering the medication should sign off administration of the medication in the resident medical record at the time of administration..

Based on record review, staff interview, and review of the facility policy, the facility failed to perform annual employee screenings of tuberculosis (TB) signs and symptoms. This had the potential to affect all of the residents residing in the facility. The facility census was 46 residents.

Findings include:

Review of the personnel file for Licensed Practical Nurse (LPN) #94 revealed a hire date of 02/05/21 with no annual screening for signs of TB.

Interview on 10/23/25 at 10:45 A.M. with the Business Office Manager (BOM) confirmed the facility had not completed an annual TB screening for LPN #94.

Interview on 10/27/25 at 1:35 P.M. with the Health and Wellness Director (HWD) #93 confirmed annual screenings for TB signs and symptoms should be completed for all employees.

Review of the facility policy titled Tuberculosis Infection Control Program revised 2021 revealed the facility would provide annual screening and surveillance of employees for latent TB infection and active TB

Based on record review, staff interview, and policy review, the facility failed to ensure residents capable of self-evacuation were evacuated in at least two fire drills a year on each shift. This had the potential to affect all of the residents residing in the facility. The facility census was 46 residents.

Findings include:

Review of facility fire drill records dated September 2024 to October 2025 revealed there were only two drills in which evacuations were conducted.

Interview on 10/27/25 at 12:41 P.M. with the Executive Director (ED) confirmed the facility had conducted only two evacuation drills since September 2024.

Review of the facility policy titled Falls, Fire, and Other Hazards undated revealed the facility should ensure residents capable of self-evacuation were evacuated during fire drills.