Three Meadows Post Acute

In the surveyor’s words

From the most serious findings on record at Three Meadows Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Dec 23, 2025

  Based on observation, medical record review, review of wound care provider documentation, review of hospital documentation, staff interview, family interview, nurse practitioner interview, review of the National Pressure Injury Advisory Panel 2025 guidelines, and review of facility policies, the facility failed to provide a timely assessment, ongoing monitoring, and interventions to prevent the development of a pressure ulcer for Resident #05, who was known to have arterial and venous insufficiency, and who was identified at risk for pressure ulcers. […]

• Actual harm, isolatedF686May 15, 2025

  Based on observation, medical record review, review of wound center documentation, staff interview, and review of a facility clinical protocol, the facility failed to provide timely assessment, monitoring, and interventions to prevent the development of a pressure ulcer. Actual harm occurred when Resident #56, who was assessed at moderate risk for pressure ulcer development, had care plan interventions for skin checks each shift with no documented evidence of the skin checks completed. Subsequently, the resident was discovered with a unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left lateral heel and no ongoing assessments were completed to determine causative factors of the wound development or need to change pressure reduction interventions. […]

• Actual harm, isolatedF689Jul 5, 2022

  Based on medical record review, review of the hospital medical records, staff and resident interview, review of a text message correspondence, and policy review, the facility failed to ensure a resident was free from an avoidable fall during incontinence care. This resulted in Actual Harm when Resident #26 fell out of bed and sustained a right leg fracture during incontinence care, when staff used improper techniques and had not utilized the assessed number of staff for bed mobility. This affected one resident (#26) out of three residents reviewed for accidents. The facility census was 92. Findings Include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Feb 14, 2022

  Based on medical record review, staff interview, and review of facility incident reports the facility failed to develop and implement fall interventions based on resident risk factors. This resulted in Actual Harm when Resident #01 sustained a distal femur fracture after a fall. This affected one resident (#01) of three residents reviewed for falls. In addition, the facility failed to complete fall investigations to identify and analyze resident risk factors. This affected three residents (#01, #02 and #03) of three residents reviewed for falls. The facility census was 88. Findings include: Review of the medical record revealed Resident #01 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. […]

• No harm, potential for more than minimal, widespreadF803Dec 5, 2022

  Based on observation and staff interview, the facility failed to ensure the menu was reviewed by the facility's dietitian. The had the potential to affect all residents who received food from the kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #41, Resident #50, and Resident #189). The facility census was 85. Findings include: Observation of the menus on 11/29/22 at 10:32 A.M. revealed no dietitian's signature. Interview on 11/29/22 at approximately 1:31 P.M. with the Food Service Director (FSD) #272 revealed the menu was created by the previous Food Service Director and was not the menu provided by the corporation. Interview on 11/29/22 at 3:43 P.M. […]