The Meadows Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 3) when on 3/19/2026 at 10:55 a.m., Resident 4 hit Resident 3 in the right eye with a closed fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 3 being subjected to physical abuse while under the care of the facility. Resident 3, sustained purplish discoloration (purple or darkened area on the skin, usually caused by bruising or bleeding under the skin), a cut (an opening in the skin caused by trauma) measuring 0.5 centimeters (cm-unit of measurement) in length x 0.1 cm in width x 0.1 cm in depth above his right eye and pain on the right eye.

Inspectors wroteBased on observation, interview, and record review, the facility:A. Failed to implement its policy and procedure (P&P) titled Food Preparation and Service, dated 11/5/2025 and failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 79 of 85 sampled residents when on 2/9/2026 [NAME] 1 thawed fish in the preparation sink without monitoring and adhering to required time and temperature guidelines for thawing, in accordance with Federal and Retail Food Code (2022) which requires that time and temperature control for safety [TCS - food items requiring strict temperature controls] foods that are slacked (the process of raising the temperature of frozen TCS foods to make it easier to cook evenly) may be held at any temperature only if the food remains frozen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected when meal tickets containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 85 of 85 residents' rights to privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. One (1) dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed and was propped open by a box when not actively in use. b. Food residue and paper trash were found on the ground surrounding the dumpster.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to:a. Ensure two (2) dented cans were separated from non-dented cans.b. Ensure the facility dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) had tight fitting cover and its surrounding area was free from trash.c. Ensure a soiled towel was not touching the base of the salad plate while [NAME] 3 was preparing the salad plate.d. Ensure [NAME] 3 washed hands when changing tasks during food preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with necessary assistance with activities of daily living, specifically with mobility and getting out of bed for three of three sampled residents (Resident 50, Resident 54 and Resident 9). This deficient practice resulted in residents remaining in bed for prolonged periods and had the potential to compromise residents' dignity, preferences, and functional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were invited to attend group activities for two of three sampled residents (Resident 50 and Resident 54). This deficient practice had the potential to result in psychosocial decline and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing monitoring and evaluation of a resident's diabetes mellitus (a metabolic disorder characterized by impaired blood glucose regulation and risk for complications) for one of five sampled residents (Resident 82) reviewed for unnecessary medications by failing to: 1. Ensure the physician-ordered Hemoglobin A1c (HgbA1c-a laboratory test reflecting the average blood glucose control over approximately 2-3 months) was obtained upon admission as ordered. The CMP was not re-ordered until 2/12/2026. 2. Ensure blood glucose monitoring results were consistently documented when obtained as two licensed nurses failed to record capillary blood glucose readings after testing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when [NAME] 1 and [NAME] 2 were unable to verbalize or demonstrate the process of safely thawing food in the preparation sink and were unable to verbalize the temperature danger zone for food (41 degrees Fahrenheit [ F, a scale of temperature]-135 F, a temperature where bacteria multiply rapidly, doubling in as little as 20 minutes). These failures had the potential to result in harmful bacterial growth and cross-contamination in food, placing 83 of 85 medically compromised residents at risk for food borne illnesses (a disease caused by consuming food or drinks that are contaminated by germs and harmful toxins [poisonous substances that cause diseases or damage when absorbed by the body] or chemicals).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the methods that conserved temperature for lunch when cold foods were not cold and hot food were not hot. The corn salad, tartar sauce, puree fish and puree rice were not in palatable temperatures. This failure had the potential to result in decrease in food intake to 78 of 85 residents on regular and therapeutic diets, resulting in unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed rice was too sticky and did not fall off the spoon during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) and pureed salad was too watery. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 14 of 85 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on interview and record review, the facility failed to discuss and provide a resident's representative with information regarding formulating an advance directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for one of eight sampled residents (Resident 87). This deficient practice had the potential for Resident 87 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to follow-up with the Preadmission Screening and Resident Review (PASARR- a mandatory federal program requiring all applicants to Medicaid-certified nursing facilities to be screened for serious mental illness [SMI] or intellectual disability [ID/DD]) recommendation to obtain a PASARR Level II evaluation (an in-depth, mandatory assessment conducted when a Level I screen indicates a potential SMI, ID/DD, or related condition [RC]) for one of one sampled residents (Resident 3). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to revise Resident 10's comprehensive person-centered care plan to include sufficiently specific and individualized interventions addressing supervision, monitoring and access to smoking materials after identifying ongoing non-compliance with smoking safety protocol, for one of one resident reviewed for smoking safety. The care plan failed to address: 1. Process of supervision by the receptionist between 8:00 a.m. and 8:00 p.m.2. Interventions to ensure other residents do not light Resident 10's cigarette.3. Activity staff monitoring while Resident 10 is smoking. 4. Specific measures to prevent burn injury related to lighter use.5. Clear parameters governing Resident 10's access to cigarette lighters. 6. Designated staff roles and responsibilities for monitoring smoking activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice by failing to reconcile and clarify a pending ophthalmology consult order upon hospital readmission for one of one (Resident 11) resident reviewed for vision services. The facility failed to: 1. Ensure a previously ordered ophthalmology consult for cataract evaluation remained active or was clarified with the physician upon the resident's return from a general acute care hospital (GACH). 2. Review and clarify any previously scheduled specialist appointments at the time of readmission to determine whether they should be continued, discontinued, or rescheduled, in accordance with the facility's readmission process. These deficient practices resulted in a delay in ophthalmologic evaluation and cataract treatment for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted daily for two of two days on 2/11/2026 and 2/12/2026. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure buprenorphine (used to treat pain and opioid use disorder [chronic use of opioids that causes clinically significant distress or impairment]) was administered sublingually (method of administering medication by placing it under the tongue to dissolve) as per the physician's order for one of five sampled residents observed during medication administration. This deficient practice had the potential for the medication not to work as intended, which can lead to the return of opioid withdrawal symptoms (physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance) and cravings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided with a Magic Cup (a high-calorie, high-protein nutritional supplement designed for individuals needing to gain weight or requiring specialized diets) as ordered by the physician for one of one sampled residents (Resident 93). This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) by failing to provide a clean shower room. This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to negatively impact their quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) responsible party (RP) was informed of the Interdisciplinary Team (IDT - a group of professionals from different fields who collaborate to achieve a common goal for the resident) Care Conference on 4/8/2025. This deficient practice violated Resident 1's RP right to participate in decisions regarding Resident 1's care, treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to provide timely intervention following notification from an outpatient infusion clinic (a medical facility where residents receive medications and fluids through intravenous [IV - administered into a vein] without being admitted to the hospital) regarding Remicade (with the generic name infliximab, a medication used to treat a range of inflammatory medical conditions including rheumatoid arthritis [RA - a condition causing joint pain and inflammation]) treatment for one of six sampled residents (Resident 1) after Registered Nurse 1 (RN 1) received notification from the outpatient infusion clinic on 5/5/2025 at 12:15 p.m. that the outpatient clinic could not administer the Remicade IV due to Resident 1 being admitted to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) received two (2) liters (a unit of measurement) of oxygen continuously according to the physician's order. This deficient practice had the potential to result in Resident 1 not receiving sufficient oxygen levels in the body, shortness of breath, difficulty with speaking, confusion, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility: 1. Failed to administer a physician prescribed medication for itchiness for one of one (Resident 43) resident investigated under pharmacy services. This deficient practice had the potential to cause the resident to have unrelieved itchiness which could result to prolonged itching and scratching possibly leading to skin injury, infection, and scarring. 2. Failed to implement the facility's medication administration policy by failing to obtain a physician's order prior to the administration of the COVID-19 (a mild to severe respiratory illness that is caused by the coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (shots that one take to teach the body's immune system to recognize and defend against harmful germs) for two out of five sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) by failing to: 1. Ensure there was documented evidence in the resident's medical record indicating a hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 30) 2. Ensure there is a designated facility staff to coordinate care and services provided by the hospice provider and the facility. These failures that the potential to prevent Resident 30 from receiving well-coordinated and comprehensive hospice services.

Inspectors wrote2. During an observation on 11/22/2024 at 6:21 p.m., observed laundry staff walking in the hallway transporting a cart of clothes uncovered. During an observation and concurrent interview with Laundry Staff 1 (LS 1) on 11/22/2024 at 6:22 p.m., observed LS 1 transporting a cart of laundry uncovered. LS 1 stated that the cart of clothes are residents' clean clothes from the laundry. LS 1 stated that when transporting clean clothes and linen the clean laundry should be covered so that the clean clothes and linen do not get dirty and contaminated. LVN 1 further stated that the clean laundry cart should have been covered but she forgot to cover the clean laundry cart prior to transport. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) was completed timely for one (Resident 63) out of 21 sampled residents. This deficient practice had the potential to negatively affect the provision of necessary care and services for this resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions healthcare treatments that are not primarily based on medication) prior to administering as needed (PRN) opioid pain medication (powerful pain-reducing medications) on multiple dates for two (Residents 7 & 8) out of three sample residents investigated under the care area of pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. A bag of wheat bread and English muffin were not labeled with an open date. b. A resident's food from home in the resident's refrigerator had no label and no received date. These deficient practices had the potential to place 83 out of 92 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review the facility failed to implement their policy on rehabilitation screening as evidenced by the facility failing to conduct a quarterly rehabilitation screen for one of three sampled residents (Resident 68). This deficient practice placed Resident 68 at risk for not maintaining, improving or restoring the resident's functional abilities.

Inspectors wroteBased on interview and review the failed to develop a facility policy and procedure (P&P) specific for a Physician Orders for Life-Sustaining Treatment (POLST- a medical order that outlines a resident's end of-life care preferences, a physician, nurse practitioner (an advanced practice registered nurse and a type of mid-level practitioner), or physician's assistant (a licensed health care professional who works with physicians to provide care) must sign the form, along with the resident; or their legally recognized health care decision maker). This deficient practice had the potential to bring confusion to facility staff or a delay of care in an event a resident becomes unresponsive.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Coronavirus Disease (COVID-19- a mild to severe respiratory illness that is caused by coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (prevents infection) policy by failing to ensure residents were screened for eligibility prior to the administration of the vaccine for two of five sampled residents (Resident 30 and Resident 68). This deficient practice had the potential for residents to receive vaccines that he/she is not eligible for or contraindicated, resulting in adverse (an undesirable or harmful effect) events.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff (Certified Nurse Assistant 1 [CNA 1]) knocked on a resident's door before entering the resident's room for one of three sampled residents (Resident 3). This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure one of nine sampled staff (Licensed Vocational Nurse 1 [LVN 1]) wore an isolation gown (protective apparel, used to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) and a face shield (a protective covering for all or part of the face that is commonly made of clear plastic and is worn especially to reduce the spread of transmissible disease) before entering Resident 2's room which was placed on novel respiratory precautions (NRP - precautions should be used for residents known or suspected to be infected with {Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]}). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for one of seven sampled residents (Resident 2). On 5/23/2024, observed Resident 2's call light hanging behind Resident 2's headboard frame. Resident 2's call light was out of Resident 2's reach. This deficient practice had the potential to result in a delay with resident care, and residents not receiving assistance with activities of daily living (ADL- fundamental skills required to independently care for oneself, such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of eight sampled residents (Resident 32, 2, and 20) by failing to: 1. Ensure Resident 32 and 2 were given a manual (operated by hand) call bell (a tool placed on a hard surface that rings and is used to get attention) to facilitate communication with staff when the facility call light system (a system consisting of a hand held button connected by a cord to a wall plate; when the button is pressed a light on the wall plate, a light above the resident's door, and a light at the nurse's station alert staff) was not functioning. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of five sampled residents (Resident 48, 54, 198). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure to take Resident 49's blood pressure (BP-measurement of the pressure of the blood pushing against the walls of the arteries) and heart rate (HR) prior to administering metoprolol, lisinopril, and losartan (medications that treat high blood pressure). This deficient practice had the potential to result in unintended complications including hypotension (low blood pressure) and bradycardia (low heart rate).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses did not administer midodrine (used to treat low blood pressure [BP - the force of blood pushing against the walls of your arteries]) outside of the physician's prescribed parameters (specific instructions that can be measured) on multiple dates for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at increased risk of experiencing adverse effects (unwanted undesirable effects related to a medication), such as uncontrolled blood pressure. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 49, 54, 198, and 11), by failing to: 1. Ensure Resident 49's vital signs (measurements of the body's most basic functions) were done every shift in accordance with the physician's order. 2. Failing to ensure routine medications were documented in the Medication Administration Record (MAR- a flow sheet where nursing documents medications and services provided to a resident daily) immediately after administration per the facility's policy for Residents 54, 198, and 11. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 42 and 32) investigated for dignity were treated with respect and dignity by: 1. Failing to ensure Resident 42 was addressed by their preferred name during a medication pass observation. 2. Failing to ensure Certified Nursing Assistant 5 (CNA 5) provided Resident 32 with full bodily privacy by failing to ensure the resident's entire right side of her body was not fully exposed while taking the resident from the shower room back to her room. These deficient practices had the potential to negatively affect the resident's sense of self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of two sampled residents (Resident 198). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 198.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for two of five sampled residents (Resident 9 and 23) by failing to: 1. Develop a care plan for the use of heparin (anticoagulant [medication that helps prevent blood clots]) for Resident 9. 2. Develop a care plan for the use of Eliquis (anticoagulant) for Resident 23. These deficient practices had the potential for Resident 9 and 23 to not receive the necessary care and services to prevent complications of the anticoagulant therapy such as bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and residents received adequate supervision to prevent accidents by failing to ensure staff did not leave residents unattended with the bed in the high position for one of eight sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 sustaining an injury from a fall.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for two of five sampled residents (Resident 299 and Resident 300). This deficient practice had the potential for Resident 299 and 300 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal (prevents infection from pneumonia [infection that infects one of both lungs]) and/or the influenza (contagious respiratory illness caused by viruses) vaccinations were offered and residents and/or their representatives were educated about the benefits and side effects of the vaccinations for two of five sampled residents (Resident 198 and 298). This deficient practice placed Resident 198 and 298 at a higher risk of acquiring and transmitting pneumonia and influenza to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to screen, educate, and offer the Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) vaccine for two of five sampled residents (Resident 198 and 298). This deficient practice placed Resident 198 and 298 at a higher risk of acquiring and transmitting COVID-19 to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) by Resident 2 for one of four sampled residents (Resident 1). On 9/5/2023, Resident 2 threw a plastic trash bin at Resident 1 causing skin discoloration (change in natural skin color) and a one centimeter (cm - unit of measurement) long skin tear (a wound that happens when the layers of skin separate) to Resident 1 ' s right upper eye that needed first aid (immediate care given to an injured or suddenly ill person) and daily wound treatments. [...]