Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowpark Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide nail care for a dependent resident. A resident who was fully dependent on staff for ADLs was repeatedly observed with elongated fingernails and dark debris under the nail beds. CNAs confirmed the resident could not perform personal hygiene or nail care independently, and an LPN was unaware the resident needed nail care until the hands were observed. Record review showed no documented refusal of nail care, multiple shower sheets with nail care not completed, and a care plan identifying the resident as dependent for hygiene needs.
Failure to address a roommate grievance in a timely manner: two residents were reported to be cursing at each other and not wanting to remain roommates, and both were agreeable to a room change. Staff said the issue was reported to the SSD and discussed in a care plan meeting, but no grievance was filed for the situation. One resident had moderate cognitive impairment (BIMS 11) and the other had intact cognition (BIMS 15).
A resident with cerebral infarction, COPD, encephalopathy, malnutrition, and bilateral hand contractures was observed repeatedly lying in bed without any hand splints, orthotics, or braces present. Staff, including a CNA and LPN, knew the resident had contractures and needed full ADL assistance but were unaware of any current splint use, while the record showed no current orders and no documentation of refusal. The care plan still listed RNP interventions for PROM and splint/brace application even though the Care Plan Coordinator confirmed the resident was no longer on contracture management or using splints and that the plan should have been revised.
Call lights were not within reach or functioning for three residents. One resident's call light was on the floor under the bed frame while the resident lay in bed, another resident's room and bathroom call system did not work when tested, and a third resident's call light box was hanging out with exposed cords and the call light was out of reach. Staff and records confirmed the residents' need for accessible call bells.
The facility failed to handle grievances effectively, as evidenced by incomplete documentation and lack of follow-up on complaints from residents and their families. Incidents included a resident left in a wheelchair for too long, another found soaked in urine, and others experiencing inadequate care. The facility's grievance policy was not consistently followed, leading to unresolved issues.
The facility failed to timely remove two residents from isolation precautions, impacting their rights to a dignified existence and self-determination. One resident, admitted with C-Diff, remained on isolation despite completing antibiotic treatment and being symptom-free, restricting her access to therapy. Another resident, admitted with COVID-19, was kept on isolation beyond the necessary period. Interviews revealed a lack of awareness and adherence to policies regarding the discontinuation of isolation precautions.
A facility failed to create a person-centered care plan for a resident with a left shoulder replacement, resulting in unaddressed pain during care. Despite the resident's moderate impairment and complaints of pain, the care plan and Kardex lacked documentation and interventions for managing the shoulder replacement. Interviews with staff revealed a lack of awareness and communication about the resident's condition, highlighting a deficiency in the care planning process.
A facility failed to involve a resident's representative in care planning, despite the resident's severe cognitive impairment and the family member's request for a meeting. The resident, with a history of COPD, dementia, and anxiety, was not supported by documentation showing family involvement in care plan meetings since admission. The Social Service Director was responsible for invitations but could not provide evidence of prior invitations to the family member.
Two residents in the facility did not receive adequate ADL services related to toileting. One resident, with moderate cognitive impairment, was observed without proper clothing and inconsistent incontinence care documentation. Another resident, with severe cognitive impairment, was found by a family member to be naked and with soaked bedding, indicating a lack of timely care. Staff interviews revealed issues with night shift duties and documentation gaps, failing to meet the expected standard of care.
Failure to Provide Nail Care for a Dependent Resident
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to ensure nail care was offered or provided for one resident who was totally dependent on staff for all ADLs. Resident #2 was observed on multiple occasions lying flat in bed and unable to answer questions related to care needs. During these observations, both hands had elongated fingernails with dark brown debris under the fingernail beds, with several nails extending at least a quarter inch to over a half inch beyond the fingertips. Staff interviews confirmed the resident was fully dependent on staff for personal hygiene and could not complete fingernail care independently. A CNA who regularly cared for the resident stated the nails were very long and soiled, but was not sure who was responsible for clipping them. Another CNA stated the resident could not perform personal hygiene care, including fingernail care, and agreed the nails should not have been that long or dirty. An LPN stated staff should watch for elongated fingernails daily and make the decision to clip them if a resident cannot express needs, but was not aware the resident needed nail care until observing the hands. Record review showed no documented refusal of nail care, shower sheets with nail care not completed on multiple dates from March through May 2026, and care plans identifying the resident as dependent for ADLs and bathing. The facility policy required residents unable to perform ADLs independently to receive assistance with grooming and nail care.
Failure to Address Roommate Grievance in a Timely Manner
Penalty
Summary
The facility failed to ensure grievances related to a room change were addressed in a timely manner for two residents who were roommates and were reported to be verbally cursing at each other and not wanting to remain roommates. During a tour, both residents stated they were agreeable to a room change at that time, and one resident explained not being able to get along with the roommate. Staff later reported that the situation had been brought to their attention by a family member and by staff who heard one resident use explicit words toward the other, and that the matter had been discussed with the Social Services Director. Record review and interviews showed the issue had been discussed in a care plan meeting involving one resident, that resident's family member, the LPN/UM, MDS staff, and the SSD, where the resident reported being cursed at about a month earlier. The SSD stated immediate action is required when something like that is heard, but also stated there were no grievances filed related to the two residents. The DON and NHA stated that when residents curse at each other or call each other names, the expectation is that they be separated, staff should report the allegation to supervision, and a grievance should have been opened and the NHA notified. The residents' records showed one resident had a BIMS of 11 with moderate cognitive impairment and the other had a BIMS of 15 with intact cognition.
Care Plan Not Revised for Contracture Management and Splint Use
Penalty
Summary
The facility failed to revise Resident #2’s care plan to reflect personal care preferences and current status related to contracture management and the use of orthotics/splints. Resident #2 had diagnoses including cerebral infarction, COPD, narcolepsy, encephalopathy, protein calorie malnutrition, Crohn’s disease, embolism, contracture of muscle at multiple sites, GERD, major depression, and anxiety. During multiple room observations, the resident was lying flat in bed, unable to answer questions about care needs, and had severely contracted upper extremities, hands, and fingers. No hand orthotics, splints, or braces were observed in the room or on the resident during these observations. Staff interviews showed that the assigned CNA and LPN were aware the resident had bilateral hand contractures and required full staff assistance with ADLs, but they were unaware of any current use of hand orthotics/splints/braces. One CNA stated the resident had used hand splints in the past, but that was many months earlier, and she was unsure whether the splints had been discontinued or lost. The medical record review showed no current physician orders for hand orthotics/splints/braces, and nursing progress notes from 2/1/2026 through 5/17/2026 did not document refusal of splints or braces. The physician assessment noted decreased PROM and contracted upper extremities, including a contracted left hand. The current care plan still included restorative nursing program interventions for PROM and splint/brace application for the left wrist, left elbow, and right elbow, including applying the splints in the morning after PROM and removing them as tolerated. It also included interventions stating the resident may remove the device per preference. However, the Care Plan Coordinator confirmed the resident was no longer on a contracture management program or RNP and no longer used hand splints or orthotics due to continued refusal, but she could not provide documentation supporting refusal. She also stated the care plan should have been revised to remove the contracture management problem area, goals, and interventions and to add a care plan for refusal of care and services related to not wearing hand splints/orthotics.
Call Lights Not Within Reach or Functioning for Multiple Residents
Penalty
Summary
The facility failed to ensure call light buttons and call light cords were within reach for three residents. For Resident #2, who had diagnoses including cerebral infarction, COPD, narcolepsy, encephalopathy, protein calorie malnutrition, Crohn's disease, embolism, contractures, GERD, major depression, and anxiety, the call light button was observed lying on the floor and slightly under the bed frame foot stand while the resident was lying flat in bed. Staff C confirmed the call light pad and cord were on the floor behind the resident and under the bed frame foot stand, and Staff B stated the resident had cognitive deficits but could use the call light at times and that call lights should be within reach while residents are in bed. For Resident #59, the call light in the room and bathroom was observed not working because pulling the cord did not illuminate the system and the light above the door also did not illuminate. Resident #59's record showed diagnoses including autistic disorder and developmental disorder of speech and language, and the care plan included using the call bell and keeping it in reach. For Resident #97, who had hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, repeated falls, and difficulty walking, the call light box in the wall was hanging out with exposed cords and the call light was not within reach, hanging off the bed on the resident's left side. Resident #97 stated he did not know where the call light was and said it had been under the bed the day before and he could not reach it then either; Staff A later found the cord stuck between the mattress and bed frame and said it was not where it was supposed to be.
Inadequate Grievance Handling in LTC Facility
Penalty
Summary
The facility failed to ensure a timely and effective grievance process for several residents, as evidenced by the lack of detailed documentation and follow-up on grievances. The Nursing Home Administrator (NHA) presented grievance logs that lacked information to identify the type of concern, which hindered the ability to track and trend issues for improvement. Resident #3 reported an incident where she was left in a wheelchair for an extended period and received a rude response from a staff member when she requested assistance. Despite her family member reporting the incident, there was no record of a grievance being filed for this resident. Resident #5's family member filed a grievance after finding the resident naked and soaked in urine, suggesting neglect during the night shift. The grievance form was incomplete, with no investigation or follow-up documented, and the family member reported not receiving any communication from the facility regarding the grievance. The Director of Nursing (DON) and NHA were unaware of the grievance until the survey, indicating a breakdown in communication and grievance handling. Other residents, including Resident #6, #7, and #8, also experienced issues related to inadequate care and staff interactions, with grievances either lacking proper documentation or follow-up. The facility's policy on grievances requires prompt efforts to resolve issues and communicate findings to the resident or their representative, but these procedures were not consistently followed, leading to unresolved grievances and dissatisfaction among residents and their families.
Failure to Timely Remove Residents from Isolation Precautions
Penalty
Summary
The facility failed to honor the rights of two residents by not removing them from isolation precautions in a timely manner according to standards of practice. Resident #3, who was admitted with enterocolitis due to Clostridium difficile (C-Diff) and major depressive disorder, was observed to have a contact precaution sign on her door even after she had completed her antibiotic treatment and was no longer experiencing diarrhea. Despite being cognitively intact, as indicated by a BIMS score of 15 out of 15, Resident #3 was kept on isolation, which restricted her access to the therapy gym and equipment, impacting her self-determination and communication rights. Resident #4, who was admitted with COVID-19 among other medical conditions, was also kept on isolation beyond the necessary period. The facility's policy required a 10-day isolation period from the start of COVID symptoms, but Resident #4 remained on contact/droplet precautions until her discharge, even though she should have been taken off isolation earlier. The Assistant Director of Nursing (ADON)/Infection Preventionist confirmed that the facility lacked a process to ensure residents were removed from isolation in a timely manner, which contributed to the oversight. Interviews with staff, including the ADON/Infection Preventionist and Licensed Practical Nurses (LPNs), revealed a lack of awareness and adherence to the facility's policies regarding the discontinuation of isolation precautions. The ADON/Infection Preventionist admitted to not having a procedure in place to track and ensure the timely removal of residents from isolation. This deficiency in the facility's infection control practices led to the unnecessary isolation of residents, thereby infringing on their rights to a dignified existence and self-determination.
Failure to Develop Person-Centered Care Plan for Resident with Shoulder Replacement
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with a history of left shoulder replacement and associated pain. The resident, who was moderately impaired with a BIMS score of 8, had a medical history that included Parkinson's disease, dementia, and the presence of a left artificial shoulder joint. Despite the resident's complaints of pain when staff pulled on his shoulder during care, the care plan and Kardex lacked documentation or interventions addressing the shoulder replacement and pain management. Interviews with facility staff, including the ADON and DON, revealed a lack of awareness and communication regarding the resident's shoulder replacement and pain. The ADON acknowledged the resident's pain and the need for staff to be informed about the shoulder replacement, while the DON provided a radiology report confirming the shoulder replacement and pain. However, the care plan did not reflect these findings, indicating a deficiency in the facility's care planning process.
Failure to Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to honor the right of a resident's representative to participate in the development of the resident's care plan. The resident, who was admitted on 07/03/2024, had a medical history that included chronic obstructive pulmonary disease, dementia without behavioral disturbance, and generalized anxiety disorder. A quarterly assessment completed on 10/08/2024 indicated severe cognitive impairment with a BIMS score of 3. Despite the resident's cognitive status, the family member reported not being invited to participate in care plan meetings, expressing concerns about the resident's weight loss and care processes. Interviews with the Social Service Director (SSD) and the Regional MDS Coordinator revealed that the SSD was responsible for inviting participants to care plan meetings. However, there was no documentation to support that the family member had been invited to any care plan meetings since the resident's admission. A progress note dated 11/21/2024 indicated a request for a care plan meeting from the family member, but it was only after the surveyor's inquiry that a meeting was held with the family member present. The facility could not provide evidence of prior invitations to the family member for care plan meetings, highlighting a deficiency in involving the resident's representative in the care planning process.
Deficiency in ADL Toileting Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) services related to toileting for two residents, resulting in deficiencies in care. Resident #2, who was moderately cognitively impaired and required total assistance for ADLs, was observed without proper clothing and with a visible diaper. The care plan for Resident #2 indicated a need for dependent assistance from two staff members for toileting, yet documentation showed inconsistent incontinence care, with some days lacking any recorded care. Resident #5, who had severe cognitive impairment, was found by a family member to be naked and with soaked bedding, indicating a lack of timely incontinence care. The family member reported the incident to staff, but no follow-up communication was received. Staff interviews revealed that the resident was found completely soaked without a brief, and the night shift was blamed for not performing their duties. The care plan for Resident #5 required limited assistance for toileting, but documentation showed gaps in care, with some days missing entries. The Director of Nursing expected aides to document incontinence care at least twice per shift, but this standard was not met, as evidenced by the documentation gaps for both residents. The lack of consistent and adequate incontinence care for these residents highlights a deficiency in the facility's ability to meet the toileting needs of its residents, as required by their care plans.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 318 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dunedin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Skilled Care Center At Mease Li | 0.2 mi | ★★★★★ | 0 | 0 |
| Aviata At Lakeside Oaks | 0.4 mi | ★★★★★ | 3 | 0 |
| Lake Haven Nursing And Rehab Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Aviata At Sand Key | 2.1 mi | ★★★★★ | 0 | 0 |
| Kensington Gardens Rehab And Nursing Center | 3.1 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Meadowpark Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.