Meadow Lakes

In the surveyor’s words

From the most serious findings on record at Meadow Lakes, in the surveyor’s own words.

• Actual harm, isolatedF744Jan 10, 2024

  Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with dementia to prevent resident-to-resident altercations for 2 of 3 residents reviewed for dementia. (Resident C, Resident D) This deficient practice resulted in Resident D experiencing a fall and sustaining an acute fracture of the right upper arm bone with moderate displacement and rotation. Finding includes: During an interview on 1/9/24 at 10:30 a.m., the Director of Nursing (DON) and Executive Director indicated a physical altercation occurred on 1/5/24 between Resident D and Resident C on a secured unit. […]

• Actual harm, isolatedF689May 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure supervision to prevent repeated falls for residents assessed to be a high risk for falls and who wandered resulting in unwitnessed falls that resulted in rib fractures, lacerations, and skin tears for 2 of 5 residents reviewed for accidents. (Resident O and Resident N) Findings include: 1. On 5/11/2021 from 1:05 p.m. to 1:15 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. She had a yellow colored bruise and a nickel sized scabbed area under her right eye. Staff were not observed to be near the resident nor supervising. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. […]

• Actual harm, isolatedF725May 12, 2021

  Based on observation, interview, and record review, the facility failed to provide sufficient staffing on the Memory Care Unit in order to provide adequate supervision to prevent falls which resulted in injury for 2 of 6 residents reviewed for accidents. (Resident O and Resident N) Findings include: 1. On 5/11/2021 from 1:05 p.m. to 1:15 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. She had a yellow colored bruise and a nickel sized scabbed area under her right eye. Staff were not observed to be near the resident nor supervising. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. Staff were not observed to be near the resident nor supervising. […]

• No harm, potential for more than minimal, patternF623Jun 5, 2024

  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. 50647 2. […]

• No harm, potential for more than minimal, isolatedF726Jun 29, 2026

  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. […]