Meadows Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600May 30, 2025

  Based on a review of clinical records, the facility's abuse prohibition policy, select investigative documentation, and interviews with the resident and facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 18) from neglect by not implementing the physician-ordered use of a mechanical lift for all transfers, resulting in actual harm in the form of a comminuted right tibia and fibula fracture requiring surgical intervention. Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect or Misappropriation of Resident Property provided on May 30, 2025, revealed the facility will provide each resident with the highest practicable physical, mental and psychological services to meet their individual… […]

• Actual harm, isolatedF760May 21, 2024

  Based on review of clinical record and select facility incident reports, and staff interview it was determined that the facility failed to assure that one resident of five sampled (Resident CR1) was free from a significant medication error that compromised the resident's clinical condition and health due to Tacrolimus toxicity. Findings include: Clinical record review revealed that Resident CR1 was admitted from the hospital to the facility on [DATE], with diagnoses, which included pneumonia and history of a kidney transplant. […]

• Actual harm, isolatedF600May 24, 2022

  Based on review of select facility policy, investigative reports, information submitted by the facility and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from physical abuse, which caused multiple lacerations to one resident (Resident 38) and minor injury to one resident (Resident 51) and neglected to provide necessary care as planned to avoid physical harm to one resident (Residents 68) resulting in minor injury, out of six sampled residents. […]

• No harm, potential for more than minimal, patternF755May 29, 2026

  Based on a review of controlled medication shift count records, select facility policy, and staff interviews, it was determined the facility failed to consistently implement procedures to maintain accurate controlled medication accountability records on three of three medication carts reviewed (Clover Unit, Bluebell Unit, and Dogwood Unit).Findings include: A review of facility policy entitled Controlled Medication-Receipt, Count, and Secure Storage, last reviewed March 1, 2026, revealed that a controlled drug count for controlled drugs (medications regulated by federal law due to their potential for abuse, misuse, dependence, or diversion which is the unauthorized transfer, use, or theft of a medication Accurate shift-to-shift controlled medication counts and documentation help ensure… […]

• No harm, potential for more than minimal, patternF686Jul 31, 2025

  Based on observations, clinical record reviews, facility policies, facility investigative documentation, manufacturer instructions, and staff and resident interviews, it was determined the facility failed to implement interventions to prevent the development of a pressure injury for two residents (Residents 58 and 6) and failed to implement physician-ordered pressure-relief measures for two residents (Residents 11 and 70) out of 28 residents reviewed. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation… […]