Meadowood Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF557Oct 7, 2025

  Based on interview and record review, the facility failed to provide one of five sampled residents (Resident 1) with nursing care in a manner that maintained his dignity and respect, when Registered Nurse 1 (RN 1):1. Did not cease performing a rectal (of, relating to, or situated near the rectum, which is the final section of the large intestine) treatment/procedure after Resident 1 complained of pain and asked RN 1 to stop.2. Did not ensure privacy during care/treatment which required Resident 1 to be partially unclothed from the waist down.3. Did not provide explanation of care/treatment to Resident 1 prior to performing an invasive (involving the introduction of instruments or other objects into the body or body cavities) rectal medication insertion. […]

• Actual harm, isolatedF658Oct 7, 2025

  Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care and services in accordance with professional standards of practice when:1. Registered Nurse 1(RN 1) performed a digital stool dis-impaction (a procedure to remove hardened, impacted stool from the rectum using a lubricated, gloved finger, which is inserted into the rectum to break up and extract the stool) procedure for Resident 1 without a physician's order.2. Facility did not provide licensed nursing staff (RN 1, Registered Nurse 2, Registered Nurse 3) sufficient education and training regarding rectal suppository (a small, solid medication plug designed to be inserted into the rectum. […]

• Actual harm, isolatedF689Jul 30, 2024

  Based on interviews and record reviews, the facility failed to provide adequate supervision and assistance to prevent a fall for one out of two sampled residents (Resident 1), when: 1. The facility's policy was not followed when Resident 1 was assisted by one staff only while using a mechanical lift to transfer Resident 1 from wheelchair to bed, and the policy indicated at least two nursing staff were needed to safely move a resident with a mechanical lift. 2. The staff completing the transfer for Resident 1 did not have a mechanical lift competency completed prior to Resident 1's fall incident on 3/21/24. These failures resulted in Resident 1 sustaining a fall on 3/21/24, resulting in a left femoral fracture (a break in the thigh bone). […]

• Actual harm, isolatedF689May 7, 2024

  Based on observations, interviews and records review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents when: 1. The facility staff took more than five minutes to answer Resident 1 ' s call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 1 turned on his call light for assistance to use the toilet. This failure resulted in Resident 1 to fall on the floor twice while attempting to go to the toilet without staff assistance causing Resident 1 to sustain right arm fracture. 2. The facility staff did not ensure Resident 2 was supervised when smoking. […]

• Actual harm, isolatedF697May 7, 2024

  Based on interviews and records review, the facility failed to ensure one of three sampled residents (Resident 5) was free from pain and discomfort when Resident 5 who had left hip arthroplasty (also known as hip replacement - a surgical procedure to replace some or all of a joint) and Chronic Pain (pain that lasts for longer than 3 months) did not receive her ordered pain medication according to the scheduled administration time. This failure resulted in Resident 5 to experience excruciating pain to the point that she was in tears. Findings: During a telephone interview with Resident 5 on 5/06/24 at 8:40 a.m., Resident 5 stated she was admitted to the facility to receive Physical Therapy after a left hip replacement. […]