Meadow Lakes

Based on interview and record review, the facility failed to ensure education in-services were completed for nursing staff for specific treatment care needs for 1 of 5 residents reviewed. (Resident B)Finding includes:The clinical record for Resident B was reviewed on 6/29/26 at 9:50 a.m. The diagnoses included, but were not limited to, quadriplegia (a form of paralysis affecting all four limbs and the torso) and central cord syndrome at C4 (cervical vertebrae 4) of the cervical spinal cord. A Physician's Order, with a start date of 4/15/26 indicated, Transanal Irrigation [a water-based bowel management tool for bowel dysfunction] Special Instructions: Instill between 500 mL [milliliters] and 1000 mL of lukewarm water per irrigation session, titrating the volume to res [resident] tolerance and clinical response. Inflate balloon catheter with 1-2 pumps of air for retention. Do Not exceed 4 pumps per session. Document irrigation volume, frequency, balloon inflation amount, and any complications and indicated it was to be done once daily. During an interview on 6/29/26 at 12:39 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected a resident's status for 1 of 5 residents reviewed for unnecessary medications. (Resident 8)Findings include:On 5/21/26 at 2:31 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, Parkinson's disease (a disorder of the nervous system that affects movement and gets worse over time), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and dementia (loss of memory, language, problem-solving and other thinking abilities). A Review of the notice of PASARR (Preadmission Screening and Resident Review), dated 2/2/22, indicated, .Level I Outcome: Dementia/MI Exclusion. Rationale: A PASRR Level II evaluation is not required at this time.The Annual MDS assessment, dated 7/1/25, indicated the resident had a current PASARR Level II.During an interview with the Social Services Director on 5/26/26 at 11:29 a.m., she indicated the resident did not have a PASARR Level II.During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for 1 of 1 random observations of medications left at the bedside. (Resident 71) Findings include: On 3/11/25 at 10:30 a.m., a medication cup with 1 large white tablet was observed on the bedside table of Resident 71. Resident 71 indicated it was her stomach medication and the nurses always left it for her to take after she had finished her meal. Resident 71's clinical record was reviewed on 3/11/25 at 11:30 a.m. The diagnosis included, but was not limited to, gastroesophageal reflux disease. The clinical record lacked documentation of a self-medication administration assessment. Current physician orders, dated 3/1/25 through 3/17/25, indicated Resident 71's medications included, but were not limited to, simethicone (for gas) tablet 125 milligrams 4 times a day. During an interview on 3/17/25 at 10:25 a.m., the Director of Nursing Services (DNS) indicated there had not been a self-medication administration assessment completed for Resident 71,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set assessment for a resident determined to have a Level II PASARR and a serious mental illness for 1 of 1 resident reviewed for Resident Assessment. (Resident 62) Findings include: Resident 62's clinical record was reviewed on 3/18/25 at 11:00 a.m. The diagnoses included, but were not limited to, anxiety, psychotic disorder with delusions and anorexia nervosa. A Level II PASARR (Preadmission Screening and Resident Review) was completed in January 2023, and indicated the resident had a serious mental illness. The Significant Change Minimum Data Set (MDS) assessment, dated 2/23/25, indicated No to Resident 62 having a Level II PASARR and no to the resident having a serious mental illness. During an interview on 3/18/25 at 10:35 a.m., the Social Services Assistant indicated the Significant Change MDS assessment, dated 2/23/25, for Resident 62 should have been coded Yes to having a Level II PASARR and Yes to the resident having a serious mental illness. On 3/18/25 at 1:20 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure staff revised the comprehensive care plan for a resident with significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 47) Findings include: On 3/11/25 from 9:20 a.m. to 9:45 a.m.,. Resident 47 was observed in bed with breakfast on her tray and no food eaten. No staff were present with the resident. On 3/14/25 from 9:25 a.m. to 9:50 a.m., Resident 47 was observed in bed with breakfast on her tray and no food eaten. No staff were present with the resident. On 3/11/25 at 10:10 a.m. Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. The Quarterly MDS (Minimum Data Set) assessment, dated 3/10/25, indicated the resident had a five percent or more weight loss in the last month or weight loss of ten percent or more in the last 6 months. The Functional Assessment, dated 3/10/25, indicated the resident required supervision or touching assistance for eating. The Follow Up Nutrition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide ADL's (Activities of Daily Living) for a dependent resident for 1 of 1 residents reviewed for ADL's. A resident was not shaved. (Resident 48) Findings include: On 3/11/25 at 10:19 a.m., Resident 48 was observed in her room with approximately half inch long whiskers on her chin. On 3/13/25 at 2:50 p.m., Resident 48 was observed in her room with approximately half inch long whiskers on her chin. At that time, Resident 48 wept and indicated having chin whiskers made her sad. She indicated staff used to shave her whiskers and she wished they did this more often, as it made her feel bad to have them on her chin. During an interview on 3/14/25 at 11:40 a.m., RN 1 indicated the resident needed her chin whiskers shaved. On 3/11/25 at 10:10 a.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. The Functional Assessment, dated 3/10/25, indicated the resident required substantial or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident received adequate assistance to prevent a fall for 1 of 3 residents reviewed for accidents. (CNA in Training 1, Resident C) Finding includes: During an interview on 12/11/24 at 11:30 a.m., Resident E indicated on 11/28/24 at approximately 10:30 a.m., she observed a new CNA in Training (CNA in Training 1) attempting to transfer her roommate, Resident C, from her wheelchair to her bed. Resident E told CNA in Training 1 Resident C required 2 staff to transfer her. CNA in Training 1 told her she could transfer Resident C by herself. CNA in Training 1 attempted to move Resident C from Resident C's wheelchair but was unable to support her, and they both slid to the floor. CNA in Training 1 left the room and brought other staff to the room to help lift Resident C to her bed. She had not seen CNA in Training 1 since the incident. On 12/11/24 at 11:55 a.m., Resident E's clinical record was reviewed. The admission Minimum Data Set (MDS) assessment, dated 10/13/24, indicated the Resident E had no cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 4 of 10 residents reviewed for hospitalization. (Resident 20, Resident 90, Resident 93, Resident 74) Findings include: 1. On 6/4/24 at 11:30 a.m., Resident 20's clinical record was reviewed. The diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage and dementia. Resident 20's progress notes indicated the resident was sent to the hospital on 3/13/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having been provided to the resident representative. 2. On 5/29/24 at 11:50 a.m., Resident 90's clinical record was reviewed. The diagnoses included, but were not limited to, sepsis and vascular dementia. Resident 90's progress notes indicated the resident was sent to the hospital on 5/5/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag was positioned off the floor to prevent infections for 1 of 2 residents reviewed for urinary catheters. (Resident 81) Findings include: On 5/29/24 at 10:43 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 5/30/24 at 9:59 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 5/31/24 at 10:45 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 6/3/24 at 9:43 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 6/3/24 at 11:02 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. Resident 81's clinical record was reviewed on 6/3/24 at 11:15 a.m. The diagnosis included, but was not limited to, obstructive and reflux uropathy due to neurogenic bladder. Physician orders, dated 5/5/24 through 6/5/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide services in accordance with professional standards for 1 of 3 residents reviewed. Staff administered another resident's medication without a physician's order. (Resident E) Findings include: During an interview on 1/9/24 at 11:28 A.M., the Director of Nursing (DON) indicated on 1/8/24 around 3:00 A.M., Registered Nurse 1 (RN 1) accidentally administered an oral dose of morphine concentrate to Resident E, who was not prescribed the medication. RN 1 was placed on suspension pending the results of the investigation. On 1/9/24 at 11:30 A.M., Resident E's clinical record was reviewed. The diagnoses included, but were not limited to, senile degeneration of brain and Alzheimer's disease with late onset. The resident began hospice care on 1/4/24 for senile degeneration of the brain. The January 2024, Medication Administration Record (MAR) did not indicate the resident was administered morphine. During an interview on 1/9/24 at 3:06 P.M., the DON indicated a physician's order for a one-time administration of a 10 milligram…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.