Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 0
Sep 24, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Meadow Lake Health Center, summarizing the results of a survey completed on 2025-09-24.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify the resident's physician and representative after a fall incident involving Resident #1.
Findings
The facility failed to notify Resident #1's physician, family, Hospice, and responsible parties after the resident had a fall on 5/10/25, which resulted in a bruise on his forehead. Staff interviews confirmed the notification was overlooked despite policy requirements.
Complaint Details
The complaint investigation found that LVN A did not notify the family, physician, Hospice, or facility leadership about Resident #1's fall on 5/10/25. The Director of Nursing and Assistant Director of Nursing confirmed notification protocols were not followed. LVN A admitted to forgetting to notify anyone and received additional training after the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician and representative after a fall incident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Length of respite care: 5
BIMS score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse who failed to notify family and physician after Resident #1's fall |
| DON | Director of Nursing | Reported not being notified of the fall until family inquiry |
| ADON | Assistant Director of Nursing | Confirmed notification protocols and that LVN A failed to notify required parties |
| CNA B | Certified Nursing Assistant | Witnessed Resident #1's fall and described events surrounding the incident |
Inspection Report
Deficiencies: 1
Aug 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether the facility developed and implemented comprehensive, person-centered care plans with measurable objectives and time frames for residents' medical, nursing, and psychosocial needs.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident #15 that included measurable objectives and time frames, and did not update the care plan to reflect diagnoses of infections or current antibiotic therapy. This failure could place residents at risk of not receiving appropriate care and services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically for Resident #15. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 4
Dates of positive urinary tract infection tests: 3
Antibiotic administration days per week: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan oversight for Resident #15 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report and appropriately investigate alleged abuse, neglect, and injuries of unknown origin involving two residents.
Findings
The facility failed to report an unwitnessed fall and an injury of unknown origin to the State Survey Agency within required timeframes. Additionally, the facility did not thoroughly investigate or report the results of these incidents involving two residents, placing them at risk for abuse, neglect, and serious bodily injury.
Complaint Details
The complaint involved two residents (#7 and #10). Resident #10 had an unwitnessed fall resulting in a laceration requiring staples, and Resident #7 had a pathological fracture of the right femur of unknown origin. Both incidents were not reported to the State Survey Agency as required, and investigations were inadequate. The Administrator and DON were unaware or did not follow up on reporting. The corporate office determined Resident #7's fracture did not meet reporting guidelines due to its pathological nature, but the facility failed to investigate or report both incidents properly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for two residents with injuries of unknown origin. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations by thoroughly investigating and reporting the results of investigations to the State Survey Agency within 5 working days for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse and neglect: 16
Residents affected: 2
Staples received: 2
Incident report dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Notified about Resident #10's fall and provided first aid; reported allegations to Administrator |
| LVN B | Licensed Vocational Nurse | Found Resident #10 on floor; notified physician about Resident #7's pain and x-ray results |
| DON | Director of Nursing | Notified about injuries to Residents #7 and #10; interviewed staff; did not follow up on reporting to State Agency |
| Administrator | Abuse Coordinator | Responsible for investigating and reporting abuse allegations; unaware of Resident #10's injury; did not investigate or report incidents |
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