Inspection Reports for
MeadowView Memory Care Village

Complaint #131877-C and Complaint #130915-C were investigated along with Incident #131197-I, Incident #131496-I, Incident #131879-I, Incident #131776-I, and Incident #132108-I. Some incidents were substantiated with regulatory insufficiencies cited.

The program failed to follow narcotic medication policies, resulting in a missing Lorazepam tablet and improper medication destruction. Incident reports lacked required details and witness statements. The program failed to provide adequate treatment and safety checks for tenants, including a tenant found on the floor for hours. Documentation of routine care and safety checks was incomplete for multiple tenants. The service plan failed to include information about a camera device in a tenant's apartment.

Investigations #131197-I, 131496+I, 131776-I, 131879-I, 132108-I, 131877-C, & 130915-C

The program failed to provide adequate and appropriate care to one tenant, Tenant C2, by not completing required continence assistance and safety checks during the overnight shift on April 1, 2026. Tenant C2 fell and remained on the floor for several hours before being found, resulting in injury and hospitalization.

Incident #130519-I

Multiple medication administration errors occurred, including early administration, crushing medication without orders, and failure to monitor tenants properly. Staff hired through a staffing agency were not delegated on all tasks within 30 days of employment.

Investigation #130519

The program failed to administer medications as prescribed, including crushing medication without orders and leaving medication unattended. Two tenants experienced adverse events requiring emergency room visits due to medication errors.

The visit was complaint-related, investigating Incident #128790-I and Complaints #125098-C and #126308-C. The investigation found no regulatory insufficiencies related to Incident #128790-I but identified deficiencies during the complaint investigations.

The facility failed to provide appropriate care and treatment for one tenant who died unexpectedly, including failure to adequately respond to symptoms indicating a possible stroke. Additionally, the program failed to timely and adequately address inappropriate sexual behavior by another tenant, with delays in updating service plans and insufficient monitoring.

Type of Action: 125098-C, 126308-C

The program failed to provide appropriate care and treatment for Tenant C1, who experienced a fall, a medication error, and symptoms of weakness and pain that were not properly communicated to nursing staff. The tenant died from a likely stroke, and the medication error was determined not to have contributed to the death.

Investigation into Complaint #123709-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the complaint investigation.

The visit was triggered by a complaint investigation of Incident #123134-I. The report details the investigation and findings related to the incident involving Tenant #3 exiting the facility unalarmed.

The facility failed to ensure an operating alarm system was connected to each exit door in the dementia-specific program, affecting one of three tenants reviewed. The investigation revealed that the front vestibule doors lacked an alarm system, allowing a tenant to exit unalarmed.

The program failed to ensure an operating alarm system was installed on the vestibule exit doors of the memory care unit, allowing a tenant with severe cognitive decline to exit the facility unsupervised. This deficiency posed a safety risk to the tenant who was found approximately 1.5 miles from the program.

Investigation of Incident #118268-I found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation of Incident #118268-I.

The investigation was triggered by incidents #110585-I and #113325-I involving Tenant #1's elopement and Tenant C1's attempted self-harm. No regulatory insufficiencies were cited related to Incident #110880-I.

The program failed to follow established policies and procedures related to door alarms and nurse notification, resulting in an elopement of Tenant #1 and inadequate nurse notification for Tenant C1's attempted self-harm incident. Additionally, service plans were not updated timely or signed as required for both tenants.

The program failed to follow door alarm policies and procedures, resulting in Tenant #1 eloping from the building without timely staff response. Staff also failed to notify the nurse of changes in behavior and oxygen saturation for Tenant C1 prior to an attempted self-harm incident.

The Program failed to have incident reports signed by the staff who completed the reports, failed to follow its policy and procedure related to incident reports for 4 of 5 tenants reviewed, failed to complete nurse delegated training for 2 of 6 staff within 60 days of employment, failed to ensure background checks were valid within 30 days for 1 of 6 staff, and failed to update service plans as needed to reflect current needs of 4 of 4 tenants reviewed.

The inspection found regulatory insufficiencies related to individualized service plans for tenants and dementia-specific education for personnel. Several tenants' service plans did not reflect their actual needs or treatments, and some staff did not receive the required dementia-specific training within 30 days of employment.

The program failed to discharge one tenant who exceeded the level of care due to physical aggression. Multiple staff reported aggressive behaviors by Tenant #1, including hitting, kicking, punching, and biting staff during care activities. The program planned to discharge the tenant due to these issues.