Meadow Lakes

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF640Mar 18, 2025

  Based on interview and record review it was determined that the facility failed to consistently ensure Minimum Data Set (MDS) assessments were submitted within the required time frame. This deficient practice occurred for 8 of 8 system selected residents (Resident #4, #6, #19, #22, #36, #42, #48, and #53) reviewed for timely submission of MDS and was evidenced by the following: On 3/12/25 at 11:01 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RNMDS) regarding the MDS'. The surveyor provided a list of MDS and requested a validation report regarding timeliness. The RNMDS stated she knew she had late MDS submission. On 3/12/25 at 1:24 PM the RNMDS provided the following validation reports: 1. […]

• No harm, potential for more than minimal, widespreadF838Mar 18, 2025

  Based on interview and document review it was determined that the Facility Assessment (FA) failed to identify and include the staff competencies and skill sets necessary to provide the type of care required for the resident population. This deficient practice had the potential to affect all residents and was evidence by the following: On 3/12/25 at 11:20 AM, the Licensed Nursing Home Administrator (LNHA) provided a copy of the FA dated July 23, 2024 which revealed an attendance sheet with an Agenda that included, but was not limited to; Data- Disease/Conditions/Physical Behaviors needs/ Cognitive disabilities/Acuity and Staff Competencies and Skill Sets. […]

• No harm, potential for more than minimal, widespreadF865Mar 18, 2025

  Based on interview and document review it was determined that the facility failed to self-identify all areas for improvement, then develop, implement and maintain a comprehensive, measurable, data driven Quality Assurance and Performance improvement (QAPI) program to address all systems and review significant events at QAPI. The deficient practice had the potential to affect all residents and was evidenced by the following: Refer to F550, F677, F678 On [DATE] at 9:22 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI program. The surveyor asked the LNHA to identify all the current QAPI plans. […]

• No harm, potential for more than minimal, patternF550Mar 18, 2025

  Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide a dignified dining experience by failing to a) provide incontinence care to a resident prior to providing the lunch meal, and b) appropriately provide dining assistance in a dignified manner, and ensure appropriate resident engagement during the lunch meal. This deficient practice occurred for 4 of 4 residents (Resident #13, #27, #29 and #46) reviewed for dining and was evidenced by the following: 1. On 3/12/25 at 12:06 PM, the surveyor observed Resident #13 in the day room next to a Certified Nursing Aide (CNA) #1 who was preparing to assist the resident with the lunch meal. […]

• No harm, potential for more than minimal, patternF689Mar 18, 2025

  Based on observation, interview, and record review it was determined that the facility failed to provide adequate supervision for a resident who was identified at risk for falls and sustained multiple falls. This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for falls and was evidenced by the following: On 3/13/25 at 8:31 AM, the surveyor observed Resident #47 in their room and was being assisted by a Certified Nursing Aide (CNA). The resident was non verbal and did not open their eyes upon approach. At the CNA then wheeled Resident #47 in into the dayroom, then shortly after returned the resident to their room and left the resident unattended in their room. […]