Meadow Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 22, 2024

  Based on observation, interview, and document review the facility failed to compressively assess falls for root cause, implement appropriate interventions and follow the care plan to prevent and/or reduce the risk of falls with major injury for 2 of 2 residents (R3 and R2) with history of falls. This resulted in actual harm for R3 when he sustained a hand fracture and lacerations to his face and foot and R2 when she sustained a laceration above the eye that required sutures as a result of a fall. […]

• No harm, potential for more than minimal, widespreadF851Feb 18, 2026

  Based on interview and document review, the facility failed to submit completed and accurate direct care staffing information for 1 of 1 quarters reviewed (Quarter 4), July 1-September 30 2025, to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 18 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D for quarter 4 identified excessively low weekend staffing, one star staffing rating, no RN hours for 11 days in quarter 4 and failed to have licensed nursing coverage 24 Hours/Day for 65 days in quarter 4. […]

• No harm, potential for more than minimal, widespreadF867Aug 22, 2024

  Based on interview and document review the facility failed to develop, implement, monitor, and evaluate falls quality improvement project (QIP) that was an identified problem-prone area to improve performance and ensure sustainability. This had the potential to affect all residents residing in the facility. Findings include SEE F689: Based on observation, interview, and document review the facility failed to compressively assess falls for root cause, implement appropriate interventions and follow the care plan to prevent and/or reduce the risk of falls with major injury for 2 of 2 residents (R3 and R2) with history of falls. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2022

  Based on observation and interview, the facility failed to properly label, date opened food items and monitor for expired items which continued to be used. This practice had the potential to affect all 20 of the residents residing in the facility at the time of the survey and any staff and visitors who may consume the kitchen prepared food items. Finding include: During the initial kitchen tour on [DATE], at 12:18 p.m. Cook (C) confirmed observations. -The standup freezer located in the kitchen was found to have a bag of frozen fajita blended vegetables opened on [DATE] in the original clear plastic bag with a twist tie holding it closed, an Imperial blend of vegetables opened and not dated, donuts were in a bag not dated. There were numerous others unknown items observed and not dated. […]

• No harm, potential for more than minimal, widespreadF888Jul 15, 2022

  Based on observation, interview and document review, facility failed to fully implement an immunization tracking and surveillance plan that was accessible and usable by the facility clinical leadership in order to monitor and ensure facility response to the Covid-19 health concern. This had the potential to impact all 20 current residents, and staff currently working at the facility. Findings include: During an interview at the survey entrance conference on 7/11/22, 12:21 p.m. the facility administrator stated the director of nursing (DON) was responsible for infection control (IC) and infection prevention (IP) in the facility and for the Covid-19 immunization and testing response. […]