Meadowood Nursing Center

F 0557 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the incident to the Charge Nurse (CN) on duty. CNA 2 stated Resident 1 was visibly upset with tears in his eyes. During a phone interview on 10/7/25 at 10:45 a.m. with Physician 1 (PHY 1), he stated digital dis-impaction required a physician's order (crucial for patient health, as it provides expertise and guidance to ensure proper treatment and avoid complications), and performing dis-impaction without a physician's order could cause resident harm because of physical pain and irritation, as well as unwanted dignity issues.During an interview on 10/07/25 at 11:00 a.m. with Resident 1, he stated he still experienced PTSD and psychological trauma from the suppository insertion on the evening of 9/15/25. Resident 1 stated he was still suffering from nightmares and did not want to eat, because he did not feel safe.During an email correspondence on 10/14/25 at 12:53 p.m. from Resident 1, he wrote that his nightmares began after 9/15/25, and continued to worsen over time. Resident 1 also wrote he still felt unsafe in the facility because of this incident and the investigation, and feared staff might try to tamper with his food. Record review of the facility policy (P & P) titled, Administering Rectal or Vaginal Medications, revised in 2010, indicated, Explain

the procedure to the resident.Provide for privacy of the resident. and gently insert the suppository into the anus with the lubricated, gloved index finger. Insert approximately 10 centimeters (a unit of measure) (4 inches) deep along the wall of the rectum.instruct resident to remain in left lateral (side) or lying position for at least five (5) minutes.Record review of P & P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised in February of 2021, indicated, Residents and resident representatives have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms, and Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risks and benefits of

the proposed care, treatment, treatment alternatives or treatment options.Record review of P & P titled Dignity, revised 2021, indicated, Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Event ID:

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowood Nursing Center

3805 Dexter Lane Clearlake, CA 95422

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to report an allegation of abuse within two hours to the DEPARTMENT for one of five (5) sampled residents (Resident 1).This finding had the potential to result in inability for the DEPARTMENT to investigate and advocate for Resident 1's rights, and possible continuous abuse to Resident 1 and other residents of the facility.Record review of the facility Face Sheet (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] with medical diagnoses which included post laminectomy syndrome (a condition, where part of the bone (lamina) covering the spinal cord is removed and causes persistent or recurring pain, tingling and numbness in the buttocks and legs) and constipation (a condition characterized by infrequent or difficult bowel movements).Record review of a form titled, SOC-341 (a specific form used in California for Mandated Reporters to document and report suspected Dependent Adult or Elder Abuse), the facility sent and was received at DEPARTMENT on 9/16/25 at 10:06 a.m., indicated, Resident [Resident 1] requested a suppository and when RN [Registered Nurse 1] went to give it he states that, she swirled the suppository around inside his rectum and it took too long. When he questioned her she stated I have to activate it, so it works .He felt violated and almost had

an erection of how long the nurse took.During an interview on 9/17/25 at 9:30 a.m., Resident 1 stated the incident occurred on 9/15/25 at approximately 10:30 p.m.Record review of a nursing note dated 9/15/25 at 10:31 p.m., indicated, RESIDENT [Resident 1] FELT VIOLATED AFTER RN (Registered Nurse 1) ADMINITERED (sic) RECTAL SUPPOSITORY. During a concurrent interview and record review on 9/17/25 at 9:58 a.m. with the Assistant Director of Nursing (ADON), a fax confirmation log showing transmissions from the facility fax was requested. The log was reviewed and showed no faxes sent (or attempted) from the facility to the DEPARTMENT on 9/15/25. During a phone interview on 9/18/25 at 11:15 a.m., the Administrator (ADM) stated she was notified on the abuse allegation made by Resident 1 at 9/15/25 at 10:58 p.m. by Charge Nurse (LVN 1), who explained she sent a fax to the DEPARTMENT within two hours of the abuse allegation (on 9/15/25) for notification purposes. The ADM stated she was unable to find evidence of this fax, therefore, she called the DEPARTMENT on the morning of 9/16/25 to confirm the DEPARTMENT received Resident 1's abuse allegation dated 9/15/25. The ADM stated the DEPARTMENT told her they did not receive notification of the abuse incident on 9/15/25, so the ADM faxed the SOC-341 to

the DEPARTMENT on 9/16/25 at approximately 9:00 a.m.Record review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 2022, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) .Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Meadowood Nursing Center

3805 Dexter Lane Clearlake, CA 95422

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/26/25, indicated, An organized health care system must develop standardized procedures before permitting registered nurses to perform standardized procedure functions. A registered nurse may perform standardized procedure functions only under the conditions specified in a health care system's standardized procedures; and must provide the system with satisfactory evidence that the nurse meets its experience, training, and/or education requirements to perform such functions.During a review of Meadowood Registered Nurse Job Description, dated 2023, it indicated, Provides direct care skills.in accordance with current policies and procedures, as assigned .Prepares and administers medications as per physicians' orders.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Record review of the facility policy (P & P) titled, Administering Rectal or Vaginal Medications, revised in 2010, indicated, Explain the procedure to the resident.Provide for privacy of the resident. and gently insert the suppository into the anus with the lubricated, gloved index finger. Insert approximately 10 centimeters (a unit of measure) (4 inches) deep along the wall of the rectum.instruct resident to remain in left lateral or lying position for at least five (5) minutes.

Event ID:

Facility ID:

If continuation sheet