The Meadows

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the possible contamination of ice, as evidenced by a buildup of a black substance on the inside door and the interior ledge of the ice machine that was used for all residents for one (1) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled Ice Machine Cleaning Policy with an effective date of 5/3/2021 revealed, .The kitchen staff will be responsible for weekly cleanings of ice machines in the kitchen .During the initial kitchen tour on 6/1/2026 at 10:24 AM, observation of the ice machine revealed two areas of black substance, each approximately two to three inches in diameter, on the underside of the ice maker lid. Black substance was also observed along the interior ledge of the ice machine. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the designated Infection Preventionist implemented and monitored the facility's Infection Prevention and Control Program by failing to conduct infection surveillance, track and trend infections, analyze infection data and identify infection control concerns. This deficient practice had the potential to affect all 118 residents residing in the facility. Findings Include:Record review of the facility policy titled Compliant Infection Preventionist (IP) Job Description revealed under, Position Summary: The Infection Preventionist (IP) is responsible for the development, implementation, oversight, and evaluation of the facility's Infection Prevention and Control Program (IPCP). [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to implement an effective antibiotic stewardship program, failed to ensure urinary tract infections (UTIs) were reviewed using established infection criteria before antibiotic treatment, failed to track and trend infection data, and failed to identify and implement interventions to reduce infections for numerous UTI episodes identified on the facility's infection tracking logs from February 2026 through April 2026. This was for three (3) of four (4) months reviewed.

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure comprehensive Activities of Daily Living (ADL) care plans were implemented for two (2) of 25 residents sampled. Specifically, the facility failed to implement established ADL care plan interventions related to facial hair for Residents #59 and #67.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to provide necessary Activities of Daily Living (ADL) services for two (2) of 25 sampled residents who were dependent on staff assistance to maintain their personal hygiene and grooming needs. Resident #59 and Resident #67.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program by failing to follow Enhanced Barrier Precautions (EBP) (Resident #91) and by failing to provide an appropriate biohazard (red barrel) container for a resident under transmission-based precautions. (Resident #118) for two (2) of 25 sampled residents. Findings Include: Review of the facility policy titled, Infection Control-Contact Isolation/Transmission Based/Enhanced Barrier Policy with a revision date of August 2024 revealed, 2. Contact Isolation. Red/Yellow bagged barrels will be utilized . Record review of physician orders revealed Resident #118 had an order dated 6/2/2026 for contact isolation precautions related to ESBL (Extended-Spectrum Beta-Lactamase) in urine every shift. [...]

Inspectors wroteBased on staff interview, record review, and review of facility-provided documentation, the facility failed to notify the medical provider prior to administering a medication that required pulse rate monitoring for one (1) of three (3) residents reviewed for medication monitoring (Resident #1). This failure resulted in a medication being administered multiple times when the resident's pulse rate was below the facility-required threshold of sixty (60), without provider notification or guidance.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the safety of a resident during a mechanical lift transfer and a resident sustained a forehead laceration requiring sutures for one (1) of four (4) residents sampled. Resident #1Findings include:Record review of facility policy titled, Total Lift Policy with revision date of 2/2/17 revealed, It is the policy of the facility that a total lift will be utilized as follows: by a licensed nurse or CNA (Certified Nursing Assistant) . It requires two employees when lift is used .A phone interview with CNA #1 on 11/3/25 at 10:40 AM, revealed she was the CNA caring for Resident #1 when the lift incident occurred. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to promote dignity by not ensuring the use of a privacy cover for the urinary catheter bag for one (1) of five (5) residents reviewed with a catheter. (Resident #2) Findings Include: Review of the facility policy titled Catheter Placement Policy, with a revision date of August 14, 2017, revealed catheter bags should be placed inside a privacy bag. Review of the facility policy titled Dignity Policy, with a revision date of September 6, 2010, revealed care should be provided in a manner and in an environment that maintains or enhances each resident's dignity with respect in full recognition of his or her individuality. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to involve a bed-bound resident for a scheduled care plan meeting for one (1) of 21 sampled residents. Resident #80 Findings Include: Review of the Care Plan Invitation Policy unrevised revealed, It is the policy of this facility that invitations to care plan conferences will be handled in the following manner: The resident and/or the responsible party will be invited to attend the care planning conference by one week prior to the scheduled date . A formal interdisciplinary care planning conference will be held weekly on Thursday. All members present are to provide input and sign the care plan verifying attendance . Review of the Resident Rights Policy with a revision date of 12/06/10 revealed under, Exercise Rights: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to allow a resident the opportunity to make important care-related decisions for one (1) of 21 sampled residents. Resident #87 Findings Include: Review of the Resident Rights Policy with a revision date of 9/06/10 revealed under, Exercise Rights: Each resident will be able to exercise his/her rights as a resident in this facility and as a citizen of the United States. An observation and interview with Resident #87 on 5/27/25 at 10:56 AM revealed she was sitting in her wheelchair in her room and stated that she did not sleep well last night and explained that they made her get up early this morning. She revealed, I told them I would rather not get up, and I wanted to sleep in. The resident stated that they made her get up anyway. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to accurately complete Section K of the Minimum Data Set (MDS) for a resident with significant weight loss for one (1) of 21 sampled residents. Resident #48 Findings Include: Review of the facility policy titled Resident Assessment Instrument Policy (RAI) with a revision date of 5/19/15 revealed, It is the policy of this facility that the RAI will be done as follows: According to the guideline specified by CMS (Centers for Medicare and Medicaid Services) . Record review of the Weights Detail Report for Resident #48 revealed the following recorded weights: 3/27/25 237.1 4/29/25 230.3 Record review of the readmission Assessment for Resident #48 dated 5/07/25 revealed a weight of 206.6, which was a significant weight loss of 10.29% (percent) from the last documented weight on 4/29/25. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to ensure that one (1) of 24 sampled residents was protected from verbal abuse. Resident #268 Findings Include: Record review of the Facility's Abuse, Neglect, or Exploitation Policy with revised date of November 21, 2017, documented, It is the policy of this facility that all residents will be free from abuse, neglect, and exploitation following the guidelines in the Vulnerable Adult Act . On 11/28/23 at 12:40 PM, an interview with Director of Nursing (DON), revealed that on 10/30/23, it was reported to her that Certified Nursing Assistant (CNA) #1 had spoken inappropriately to a resident. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to accurately complete a Pre-admission Screening (PAS) for a resident with a mental disorder for one (1) of two (2) resident PASSARs (Pre-admission Screening and Resident Review) reviewed. Resident #35 Findings Include: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program with an implementation date of 07/10/23 revealed under the Policy: This facility coordinates assessments with pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Record review of Resident #35's Record of Admission revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on staff interview and record review the facility failed to have a stop date on an As Needed (PRN) psychotropic medication for one (1) of three (3) residents reviewed for the use of psychotropic medications. Resident #58 Findings Include: Review of the typed statement on facility letterhead (undated) revealed the facility did not have a policy regarding a stop date for psychotropic medications and was signed by the Administrator. Record review of Resident #58's Physician's Orders revealed the following: Order dated 7/20/23-Lorazepam oral concentrate 2mg (milligrams)/1ml (milliliter) give 1ml every 2 (two) hours as needed for anxiety oral. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy reviews the facility failed to transmit Annual and Quarterly Minimum Data Set (MDS) Assessments accurately and timely for two (2) of two (2) residents reviewed for MDS assessments.