The Meadows on University

Inspectors wroteBased on review of resident council meeting minutes, review of facility policy, confidential resident, family, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available to meet the residents' need for 4 of 18 sampled residents (Resident E, J, N, and P), and 12 supplemental residents (Resident A, B, C, D, F, G, H, I, K, L, M, and O) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for all residents. Findings Include: Review of facility policy titled Call lights: Accessibility and Timely Response occurred on 06/10/26. This policy, dated 06/15/25, stated, . All staff members who see or hear an activated call light are responsible for responding. [...]

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to provide the necessary services for 4 of 18 sampled residents (Resident #1, #10, #30, and #55) who required assistance with bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem.

Inspectors wroteBased on observation and staff interview, the facility failed to provide adequate housekeeping services to prevent accidents on 1 of 4 days of survey (06/07/26). Failure to clean standing water from the floor placed residents, staff, and visitors at risk of falls and injury.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure food items were stored and monitored in a safe manner in 1 of 1 kitchen and 1 of 1 kitchenette observed. Failure to properly store, label, date, monitor, and discard food items may result in the consumption of unsafe food and place residents at risk for foodborne illness.

Inspectors wroteBased on observation, review of facility policies, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 7 sampled residents (Resident #2 and #7) observed during cares, 1 of 5 residents observed during medication pass (Resident #19), and one laundry room. Failure to follow infection control standards related to hand hygiene, glove use, medication administration, the use of personal protective equipment (PPE) and enhanced barrier precautions (EBP), and storage of soiled/clean items within the laundry room has the potential to spread infection throughout the facility. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/09/26. [...]

Inspectors wroteBased on review of Medicare Part A letters/notices, review of facility policy, and staff interview, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #43 and #81) reviewed for termination of Medicare Part A services. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 4 of 4 days of survey. Failure to ensure the resident environment and equipment are kept clean and sanitary does not promote a homelike living environment or enhance the residents' quality of life.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #1 and #30). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observations, record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 supplemental resident (Resident #57) observed with a wound dressing. Failure to follow physician's orders regarding dressing changes may result in delayed treatment, infection, and increased wound complications.

Inspectors wroteBased on observation, review of facility policy, and review of manufacturer's instructions, the facility failed to ensure a medication error rate of less than five percent for 2 of 25 medications observed during medication administration. Two medication errors occurred during staff administration of 25 medications, which resulted in an eight percent error rate. Failure to follow facility policy and pharmacy instructions may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure posting of resident census on 3 of 4 days of survey (June 7, 2026 - June 9, 2026). Failure to post the resident census may impede the facility's ability to evaluate staffing levels in relation to the number of residents residing in the facility.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to develop a baseline care plan to reflect the needs for 1 of 1 sampled resident (Resident #1) identified as a new admission. Failure to develop and implement a baseline care plan may result in inconsistent and unsafe care for all newly admitted residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #1) on contact precautions. Failure to practice infection control standards related to contact precautions and hand hygiene for staff and residents has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (Resident #47) with weight loss. Failure to monitor/document intakes accurately and provide encouragement and assistance with meals and supplements resulted in a significant weight loss.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 6 of 15 sampled residents (Resident #2, #6, #16, #36, #43, and #47) dependent on staff assistance for personal hygiene and dining. Failure to assist residents who cannot perform personal hygiene, position self, or open items at meals may result in poor hygiene, skin issues, weight issues, and decreased self-esteem.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen. Failure to ensure dishware is stored in a clean area and failure to ensure the floors and warewashing machine are free from food/dust debris has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 8 sampled residents (Resident #2, #6, #8, #36, and #50) and one supplemental resident (Resident #15) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 15 sampled residents (Resident #6). Failure to honor the resident's request during cares and ensure staff speak respectfully does not promote the resident's self-esteem, preserve the resident's personal dignity, and may affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 15 sampled residents (Resident #6). Failure to place call lights within reach may result in an inability for residents to call for help, an increased risk for falls, and discomfort.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 15 sampled residents (Residents #4, #26, and #36). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and resident and staff interviews, the facility failed to provide the necessary care and treatment for 1 of 3 sampled residents (Resident #6) with impaired skin integrity and concerns of incontinence care. Failure to assess, monitor, and treat skin issues in a timely manner may have resulted in a delay of treatment and risk for further skin breakdown. Failure to provide routine incontinence cares (check and change) placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, and urinary tract infections.

Inspectors wrote1. Based on observation, record review, review of manufacturer's instructions for use, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 resident (Resident #1) who required rapid-acting insulin. Failure to administer rapid acting insulin within the time frame specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction.

Inspectors wroteBased on record review, review of a professional reference, and resident and staff interviews, the facility failed to provide appropriate toileting for 1 of 1 confidential resident (Resident A) who required staff assistance with toileting/check and change. Failure to provide toileting/check and change may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on observation, review of facility policy, and resident interviews, the facility failed to serve foods at palatable temperatures for 2 of 2 sampled residents (Resident #1 and #3) who received a meal tray in their room. Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 supplemental resident (Resident #7) who tested positive for influenza and 1 of 6 sampled residents (Resident #3) observed during cares. Failure to practice infection control standards related to influenza precautions and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, professional reference, and resident and staff interview, the facility failed to follow professional standards for 1 of 1 sampled resident (Resident #13) observed during blood glucose testing and insulin administration. Failure to clarify orders regarding the timing of blood glucose testing and administration of sliding scale insulin may result in inaccurate/inconsistent readings and insulin needs.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications for 1 of 3 sampled residents (Resident #11) who received an as-needed (PRN) psychotropic medication. Failure to ensure the provider indicates the duration for the PRN order when documenting the clinical justification for continued use of a PRN psychotropic medication may result in the resident receiving the medication for an excessive duration and/or experiencing adverse side effects related to its use.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 10 residents (Resident #23 and #294) observed during medication administration. Three medication errors occurred during staff administration of 27 medications, resulting in an 11% error rate. Failure to properly administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure appropriate labeling of medications for 2 of 10 residents (Resident #13 and #37) observed during medication administration. Failure to ensure medication cards contain the correct administration information may result in medication errors and adverse drug effects.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents (Resident #14, #27, and #32) and one supplemental resident (Resident #29). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 2 of 5 sampled residents (Resident #20 and #27) on oxygen. Failure to clean personal fans and oxygen concentrator filters does not provide a safe and clean environment and has the potential to place the residents at risk for illness.