Meadowood

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF585Feb 2, 2026

  Based on resident and staff interviews, it was determined that the facility failed to implement grievance process including required regulatory requirements of grievance policy, maintaining evidence demonstrating the result of all grievances and failed to ensure grievance forms were available for one of one nursing units observed. ( 2nd floor north nursing unit)Findings include: Review of facility policy Grievance/ Complaint Policy dated June 2023, revealed that ach grievance will be investigated and promptly resolved, keeping the resident and resident representative informed throughout the investigation. […]

• No harm, potential for more than minimal, isolatedF605Feb 2, 2026

  Based on review of resident records, pharmacy documentation and interviews with staff determined the facility failed to ensure residents' drug regimen was free from unnecessary drugs for excessive duration, without adequate monitoring and/or adequate indications for its use for two of 13 resident records reviewed (Resident R5 and R6). Findings include: Resident R5 was admitted to the facility on [DATE], on hospice, diagnosed with anxiety disorder. Physician orders dated July 5, 2025, instructed to give 0.5 mg of Lorazepam every 4 hours, PRN (as needed) for anxiety with no indication of a stop date or when this medication should no longer be administered. […]

• No harm, potential for more than minimal, isolatedF610Feb 2, 2026

  Based on clinical record review, interviews with staff and reviews of facility policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of neglect for one of 13 residents reviewed. (Resident R5) Findings include: Review of the facility's policy titled, Freedom from Abuse, Neglect, and Exploitation, revised April 2023, states, Each resident will be protected from and free from abuse. The policy defines neglect as failure through inattentiveness, carelessness, or omission to provide timely, consistent, safely adequate, and appropriate services, treatment, or care, including but not limited to supervision and serves that the facility has agreed to provide. […]

• No harm, potential for more than minimal, isolatedF881Feb 2, 2026

  Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols for one resident that received antibiotics with inappropriate use of 13 resident records reviewed (Resident R4). Findings Include:A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. […]

• No harm, potential for more than minimal, isolatedF657Jul 19, 2023

  Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to revise one resident's care plan with updated interventions status post fall for one of two residents reviewed for falls (Resident R25). Findings Include: Review of facility policy Care Plan Process, revised October 2017, revealed the plan of care is continually reviewed and updated by members of the interdisciplinary team to reflect the current needs of the resident. Review of facility policy Fall management Guideline, revised December 2022, revealed to reduce the risk of falls or fall related injuries the facility will implement appropriate person-centered interventions and the resident's plan of care will be updated accordingly. […]