Inspection Reports for
Meadowlark Hills Retirement Community
2121 Meadowlark Rd, Manhattan, KS 66502, KS, 66502
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 117
Deficiencies: 5
Date: Apr 9, 2025
Visit Reason
The inspection was a routine survey of Meadowlark Hills nursing home to assess compliance with regulatory standards including resident care, infection control, food safety, hospice services, and immunization policies.
Findings
The facility had multiple deficiencies including failure to provide written bed hold policy information to residents transferred to hospital, inadequate food service sanitation, incomplete hospice care plan details, failure to maintain infection control during wound care, and failure to follow CDC pneumococcal vaccination guidelines.
Deficiencies (5)
F 0625: The facility failed to provide written bed hold policy information to residents R35 and R5 when transferred to the hospital, risking their ability to return to the nursing home.
F 0812: The facility failed to store, prepare, distribute, and serve food according to professional standards, with issues such as rusty shelving, dried food debris, and unclean equipment in the kitchen.
F 0849: The facility failed to include hospice service visit frequency, medications, medical equipment, and resident representative preferences in the care plan for resident R69, risking inadequate end-of-life care.
F 0880: The facility failed to maintain standardized infection control practices during wound care for resident R26, as gloves were not changed between tasks, increasing risk of wound infection.
F 0883: The facility failed to follow CDC guidelines by not offering or obtaining informed declination for pneumococcal PCV20 vaccination for residents R36, R63, R70, R80, and R85, risking disease spread and complications.
Report Facts
Resident census: 117
Sample size: 25
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of signed bed hold policy for residents R35 and R5 |
| Dietary Staff CC | Dietary Staff | Verified cleaning needs in kitchen and performed cleaning |
| Dietary Manager BB | Dietary Manager | Acknowledged kitchen cleaning issues and staff cleaning procedures |
| Certified Nurse Aide M | Certified Nurse Aide | Reported hospice services for resident R69 |
| Licensed Nurse G | Licensed Nurse | Verified hospice care details and infection control breach during wound care |
| Consultant GG | Consultant | Performed wound care on resident R26 and failed to change gloves as required |
| Administrative Nurse E | Administrative Nurse | Acknowledged failure to offer pneumococcal vaccine to eligible residents |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 1
Date: Feb 3, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with nursing home regulations and ensure resident safety.
Findings
The facility failed to ensure Resident 1 was properly secured with the safety belt in a mechanical spa lift chair during transfer, resulting in a fall and a fractured right femur. Corrective actions including staff education and competency demonstrations were implemented prior to the survey.
Deficiencies (1)
F 0689: The facility failed to ensure Resident 1 was secured with the safety belt in a mechanical spa lift chair during transfer, resulting in a fall and a fractured right femur requiring surgical repair.
Report Facts
Residents present: 119
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in finding for failing to buckle spa lift chair safety belt correctly |
| LN G | Licensed Nurse | Reported CNA M failed to buckle the seat belt correctly |
| Administrative Nurse D | Administrative Nurse | Reported expectation for staff to fasten spa lift chair safety belt correctly and investigation findings |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of medication by a licensed nurse involving Resident 1's promethazine-codeine liquid medication.
Complaint Details
The investigation was substantiated based on camera footage, witness statements, and medication count discrepancies confirming the licensed nurse's misappropriation of Resident 1's medication.
Findings
The facility failed to ensure Resident 1 remained free from misappropriation when a licensed nurse emptied the resident's medication into a water bottle and took it off-site. The investigation included witness statements, medication counts, and camera footage confirming the misappropriation, leading to the termination of the nurse involved.
Deficiencies (1)
F 0602: The facility failed to protect Resident 1 from misappropriation of medication when a licensed nurse emptied promethazine-codeine liquid into a water bottle and removed it from the facility. This placed the resident at risk for missed medications and further misappropriation.
Report Facts
Resident census: 121
Medication volume: 120
Medication volume: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication misappropriation finding and terminated after investigation |
| LN J | Licensed Nurse | Witness to narcotic count and key exchange during medication misappropriation incident |
| LN H | Licensed Nurse | Discovered medication discrepancy during narcotic count and reported it |
| Administrative Nurse D | Administrative Nurse | Led investigation, interviewed staff, and terminated LN G |
| Administrative Nurse E | Administrative Nurse | Received report of medication discrepancy and conducted medication audit |
| Administrative Staff A | Administrative Staff | Provided statements regarding staff expectations on medication discrepancies |
Inspection Report
Routine
Census: 120
Deficiencies: 13
Date: Jul 19, 2023
Visit Reason
Routine inspection of Meadowlark Hills nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility failed to notify physicians of significant weight changes and fluid intake variances for multiple residents, did not maintain clean wheelchairs for some residents, failed to notify the Long-Term Care Ombudsman of a resident's hospital discharge, lacked comprehensive care plans for residents with specific needs, failed to complete required assessments for antipsychotic medications, improperly managed medication administration including expired vaccines and diuretic holds, and failed to maintain sanitary food handling practices.
Deficiencies (13)
The facility failed to notify physicians of weight gain or loss exceeding three pounds for residents R55, R106, and failed to notify physician of fluid intake exceeding orders for R71.
The facility failed to provide a clean environment for residents R7 and R66 whose wheelchairs were soiled with dried food particles and stains.
The facility failed to notify the Long-Term Care Ombudsman of resident R53's discharge to the hospital.
The facility failed to develop a comprehensive care plan for resident R71 receiving dialysis and for resident R26 at risk for aspiration.
The facility failed to revise the care plan for resident R66 with interventions to prevent skin tears despite multiple skin tears occurring.
The facility failed to assess resident R8 for safe use of an electric lift chair after a fall from the chair.
The facility failed to identify the need for increased staff assistance for resident R16 who had multiple falls with staff present.
The facility failed to monitor and enforce physician ordered fluid restriction for resident R55, placing the resident at risk for dehydration or fluid overload.
The facility failed to implement resident R71's physician ordered fluid restriction related to dialysis and failed to involve the physician or dialysis center.
The facility failed to hold diuretic medications for resident R26 when blood pressure readings were outside physician ordered parameters.
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months for residents R66 and R84 receiving antipsychotic medications.
The facility failed to dispose of expired influenza vaccine doses in a timely manner.
The facility failed to serve food in a sanitary manner in one household, including failure to wash hands, use hair restraints properly, and handling food with bare hands.
Report Facts
Resident census: 120
Weight changes not reported: 4
Weight changes not reported: 4
Fluid intake exceeding orders: 24
Expired vaccine doses: 7
Blood pressure readings outside parameters: 5
Fall risk score: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified multiple findings including fluid restriction noncompliance, care plan deficiencies, and AIMS assessment issues | |
| Licensed Nurse G | Verified fluid intake tracking and wheelchair safety issues | |
| Licensed Nurse I | Reported on care plan and fall risk for resident R26 and R16 | |
| Licensed Nurse K | Verified failure to notify physician of weight changes for R106 | |
| Licensed Nurse H | Verified weight notification procedures for R55 | |
| Certified Nurse Aide M | Observed food handling violations |
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 9
Date: Oct 13, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards for nursing home care.
Findings
The facility had multiple deficiencies including failure to notify physicians of out-of-parameter vital signs, unsafe and unsanitary environment conditions, failure to notify ombudsman of resident discharge, failure to update care plans for pressure ulcers, inadequate pressure ulcer prevention and care, inadequate supervision to prevent falls, failure of pharmacist to report medication issues, failure to hold medications when vital signs were out of range, and failure to ensure stop dates for PRN psychotropic medications.
Deficiencies (9)
F580: Facility failed to notify physicians of residents' heart medications held due to blood pressure or heart rate below ordered parameters, risking adverse medication side effects.
F584: Facility failed to provide a safe, functional, sanitary environment, with stained carpets in two households, risking an unhomelike environment.
F623: Facility failed to notify the Ombudsman of a resident's discharge to hospital, risking lack of advocacy for the resident.
F657: Facility failed to update and revise the care plan for a resident with a new left heel pressure ulcer, risking further skin breakdown.
F686: Facility failed to initiate appropriate interventions to prevent development of heel pressure ulcers for a resident at risk, resulting in an unstageable left heel pressure ulcer.
F689: Facility failed to provide adequate supervision and assistance to prevent falls for a cognitively impaired resident, resulting in a fall with injury.
F756: Consultant pharmacist failed to notify facility leadership of medication issues including lack of stop date for PRN psychotropic medication and medications administered or held outside physician parameters.
F757: Facility failed to hold medications when blood pressure and/or pulse were below physician ordered parameters, risking adverse side effects.
F758: Facility failed to ensure a stop date for PRN psychotropic medication, risking unnecessary medication use.
Report Facts
Resident census: 127
Medication holds for Coreg: 39
Medication holds for Coreg: 24
Medication holds for Coreg: 7
Medication holds for digoxin: 12
Medication holds for digoxin: 6
Medication holds for digoxin: 1
Pressure ulcer size: 5.3
Pressure ulcer size: 3.7
Pressure ulcer size: 4
Pressure ulcer size: 2
Fall injury size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Verified failure to notify physician of held medications for Resident 47 |
| Administrative Nurse E | Administrative Nurse | Verified failure to notify physician of held medications for Resident 47 and pharmacist issues |
| Licensed Nurse K | Licensed Nurse | Verified failure to notify physician for Resident 28 and failure to hold medications for Resident 47 |
| Administrative Nurse D | Administrative Nurse | Verified failure to notify physician for Resident 28 and failure to hold medications for Resident 47 |
| Licensed Nurse J | Licensed Nurse | Verified pressure ulcer care and observations for Resident 63 |
| Administrative Staff A | Administrative Staff | Verified environmental deficiencies with carpet stains |
| Administrative Staff B | Administrative Staff | Verified failure to notify Ombudsman of resident discharge |
| Certified Nurse Aide N | CNA | Assisted Resident 28 after fall |
| Certified Nurse Aide O | CNA | Assisted Resident 28 after fall |
| Certified Nurse Aide M | CNA | Reported Resident 28 fall and toileting schedule |
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