Meadow Lakes
MEADOW LAKES in EAST WINDSOR, NJ — inspection on March 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor asked the LNHA to identify all the current QAPI plans.
The LNHA stated that call bell response was identified from the resident council, and from grievances and the LNHA provided the surveyor with the QAPI plan which was reviewed in the presence of the LNHA.
The Problem Statement revealed: Staff are to answer call lights.; The SMART Goal revealed: To respond residents need and request expeditiously and appropriately at all times.; The Root Cause/s: What are the contributing factors that cause the problem? Staff not mindful of the call lights and Staff forget to turn off the call lights after answering their needs.; What is the importance of this goal? To respond resident's needs appropriately in a timely manner.; Barrier/s: What difficulties will you encounter implementing your goal?
The surveyor asked the LNHA since the date of the goal is [DATE], where is the measurable progress documented.
The LNHA reviewed the QAPI in the presence of the surveyor and stated, I don't see the SMART goal is measurable.
When asked what SMART meant the LNHA stated, we are not making it measurable.
When asked what the remaining QAPI plans were, the LNHA stated, that the facility identified that the staff were not all completing the online education system.
When asked to provide the QAPI, the LNHA stated they were in the middle of it.
When asked about a specific and measurable goal, the LNHA stated she did not have a document to show the surveyor, but the performance had improved from 40 to 70%.
The LNHA stated the facility had a QAPI on the inconsistent availability of the resident weights.
The surveyor asked if the goal was specific and measurable and the LNHA stated, I don't have it, maybe the Dietitian, had it?
The LNHA stated there was a QAPI with falls with major injury.
The surveyor asked if falls with major injury was an adverse event? The LNHA stated, yes, and it went into the internal risk management system.
The surveyor asked if adverse events were reviewed in QAPI and she stated, no, I don't see it here, I cannot show it to you.
The surveyor asked the LNHA if hand hygiene during meals and standing and cutting resident meals has been identified as a concern per surveyor observations.
The LNHA stated, that has not been identified as an issue or had any concerns regarding that brought to her attention.
315022
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315022 B.
Wing 03/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520