Cool Meadow Care

Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes…the facility shall provide assistance and care for the resident in those activities… resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.This requirement is not met as evidence by: R1 was observed to be restrained on two different occasions (9/12/22 & 9/13/22) using a handmade restraint limiting the use of R1’s ability to move. S1 admitted during the interview conducted on 9/16/25 that she had used a homemade belt made from a bed fitted sheet on R1’s wheelchair.

Based on interview and record review, the licensee did not comply with the section cited above. LPA was unable to confirm the facility is conducting the required Emergency Disaster Drills. No documentaion was present at the facility during today's inspection,which poses a potential safety risk to persons in care.

Based observation and interview, the licensee did not comply with the section cited above in one fire extinguisher last inspected on 12-04-2023 which poses an immediate health, safety or personal rights risk to persons in care..

Based on observation and interviews , the licensee did not comply with the section cited above. The water temperature was measured at 148.4 degrees, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above. LPA was unable to confirm that the facility an Emergency and DIsaster plan du to documentation not being present at the facility during today's inspection. whichposed a potential health, safety or personal rights risk to persons in care.

Additional Personal Rights of Residents…(a) In addition to the rights listed ... residents...shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions.... This requirement was not met as evidenced by: Based on interviews and records review it was found that the facility did not accept R1 back from the hospital. This poses an immediate health safety or personal rights risk to residents in care.

Based on observation and testimony given by Liz Baclagan, the licensee did not comply with the section cited above in zero out of one Carbon Monoxide detector in the facility which poses an immediate health, safety or personal rights risk to persons in care.

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement was not met as evidenced by: LPA observed that R1's bed has full bed rails. Administrator confirmed that R1 is not receiving hospice services. This poses an immediate health, safety, and personal rights risk to residents in care.

87458 Medical Assessment (1)(b) (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement was not met as evidenced by:LPA reviewed two LIC602, physician's report from R1's file and neither forms list a primary and secondary diagnosis/es. This poses a potential health, safety, and personal rights risk to resident in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above with staff member S1 that was not transferred to the facility. This poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above with centrally stored medications that were left unlocked. This posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above with powedered bleach that was found under the sink of a residents shared bathroom. This poses a potential health, safety or personal rights risk to persons in care.