Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowview Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, behavioral disturbance, and severe functional dependence and another resident with severe dementia, impulsiveness, and wandering risk were both found tied to their wheelchairs with sheets wrapped around their abdomens and secured behind the chairs. Staff reported using the sheets to keep the residents from getting up, and multiple CNAs confirmed the residents should not have been tied to their chairs. The DON and Administrator acknowledged the restraints were inappropriate, and the Administrator stated a reasonable person restrained this way would have experienced psychosocial harm.
Staff failed to immediately report alleged abuse involving unauthorized physical restraints after finding two residents tied to their wheelchairs with sheets. A CNA admitted to restraining one resident, and an LPN and other CNA staff saw the second resident restrained but did not promptly notify the DON or Administrator as required by policy. Both residents had severe cognitive impairment and significant dementia-related diagnoses.
A resident with severe cognitive impairment, tracheostomy, and dependence on staff for ADLs did not receive the ordered oral hygiene care every shift as outlined in the care plan. The care plan required morning and nighttime oral care, but observation revealed white debris on the resident’s lips, and staff interviews showed that CNAs and an RT had differing understandings of who was responsible for providing oral care. An LPN confirmed the resident had not received oral care the previous day, and leadership confirmed that CNAs were responsible for providing oral care each shift and that this had not occurred.
A resident with severe cognitive impairment, multiple sclerosis, hemiplegia, and a Stage 4 sacral pressure ulcer had physician orders and a care plan for sacral wound care three times weekly and as needed when soiled. During an observed treatment, a treatment nurse removed a saturated sacral dressing and completed the ordered wound care while leaving a soiled brief in place, then secured the same soiled brief on the resident afterward and replaced the bed linens. The nurse acknowledged the brief was soiled during treatment, and the DON stated the brief should have been changed before and not left on after the wound care, contrary to the facility’s pressure injury prevention policy requiring residents to be kept clean and dry.
A resident with chronic respiratory failure, lumbar osteomyelitis, complete paraplegia, a sacral pressure ulcer, and a tracheostomy had only one documented face-to-face physician visit during an extended stay, despite requirements for physician evaluation at least every 60 days. Record review showed a single visit shortly after admission with no further face-to-face physician encounters documented, and the DON confirmed that additional 60-day visits should have occurred but did not.
A resident with significant physical and mental health needs, who required substantial assistance for bathing, did not receive this care for a two-week period. Staff incorrectly documented bathing as 'not applicable' instead of providing and recording the required ADL care, as confirmed by interviews with the resident and facility staff.
A resident with multiple serious diagnoses, including heart failure and kidney failure, was prescribed Furosemide for edema. Despite care plan and physician orders requiring monitoring, staff did not document or monitor the resident's edema while the diuretic was administered. This lapse was confirmed by both an LPN and a corporate nurse during interviews.
A resident with diabetes, an open wound, and dementia was transferred to the hospital without a required head to toe skin assessment by an LPN, and a CNA failed to report a newly observed skin injury. The facility did not follow its policy for skin integrity monitoring and notification of changes in skin status.
A facility failed to prevent pressure ulcers for a resident with severe cognitive impairment and multiple medical conditions. Despite a care plan requiring repositioning every two hours, there was no documentation of these actions on specific shifts, leading to the development of a stage 2 pressure ulcer. Interviews confirmed the lack of adherence to the care plan.
A resident with severe cognitive impairment suffered a fall resulting in a right femur fracture. The facility failed to report the injury of unknown source with serious bodily injury to the state agency within the required 2-hour timeframe, as per their Abuse Prohibition Policy. The incident was reported approximately 12 hours after the injury was confirmed by x-ray.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and multiple fractures. The care plan lacked measurable objectives and timeframes, and necessary interventions, such as monitoring a cast and using a stabilizer, were not implemented. This deficiency was confirmed by the Corporate Nurse during an interview.
A facility failed to ensure residents were free from accident hazards by not completing quarterly fall risk assessments and not implementing specific interventions for a resident with severe cognitive impairment. The resident experienced a fall resulting in a femur fracture, and interviews confirmed the absence of documented interventions and adherence to the facility's Fall Prevention Program policy.
A CNA in an LTC facility failed to follow the Incident/Accident policy by moving a resident found on the floor before a nurse's assessment. The resident, with severe cognitive impairment and multiple health issues, was at risk for falls. The CNA's actions did not align with the facility's procedures, as confirmed by the DON.
The facility failed to complete a discharge assessment for a resident who was sent to the hospital due to worsened wounds and abnormal vital signs. Both the MDS RN and the Corporate Nurse confirmed that the discharge MDS was not completed as required.
The facility failed to apply splints as ordered for two residents with limited range of motion. One resident with anoxic brain damage and muscle atrophy did not have bilateral hand splints applied on multiple dates, and another resident with Parkinson's disease and muscle wasting did not have a right-hand splint applied on several dates. Observations and staff interviews confirmed these deficiencies.
The facility failed to change the enteral feeding container every 24 hours for a resident with multiple medical conditions, as required by physician's orders. Observations and staff interviews confirmed the deficiency.
The facility failed to ensure annual performance reviews for three CNAs, as their personnel records lacked evidence of such reviews. The Administrator confirmed the absence of these reviews during an interview.
The facility failed to ensure that a resident with moderate cognitive impairment and multiple medical conditions had access to a call light, as it was repeatedly found on the floor behind the bed. The resident confirmed the inability to reach the call light, and a CNA verified this observation.
The facility failed to ensure proper garbage disposal, as multiple trash bags and loose trash were found scattered around the dumpster, and the dumpster lids were not closed. The Maintenance Director confirmed the trash should be inside the dumpster and the lids should be closed.
Residents Tied to Wheelchairs With Sheets
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required to treat their medical conditions. Survey findings identified two residents who were tied to their wheelchairs with sheets wrapped around their abdomens and secured behind the wheelchairs. The facility policy stated that restraints were not to be used for discipline or convenience and were only to be used after assessment and evaluation of causative factors and less restrictive alternatives, except in an emergency. One resident had diagnoses including Alzheimer’s disease with late onset, dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder, anxiety disorder, schizophrenia, ischemic heart disease, and muscle wasting and atrophy of both upper arms. The resident’s MDS showed severe cognitive impairment with a BIMS score of 6 and the resident required substantial to maximal assistance with sit-to-stand and chair-to-bed transfers. The care plan addressed behavior problems related to attempting to stand from the wheelchair and included anticipating needs and redirecting as needed. A CNA reported placing a sheet around the resident’s abdomen, running it through the wheelchair sides, and tying it in the back to keep the resident from getting up because of falls. The second resident had diagnoses including Alzheimer’s disease with late onset, insomnia, cognitive communication deficit, impulsiveness, disorientation, major depressive disorder, and severe vascular dementia with agitation. The resident’s admission MDS showed a BIMS score of 0, indicating severe cognitive impairment, and the resident was dependent with sit-to-stand and required supervision or touching assistance with chair-to-bed transfers. The care plan addressed wandering risk and included re-orientation as needed. Multiple staff members reported seeing this resident tied to the wheelchair with a sheet around the abdomen and tied behind the chair, and staff confirmed the resident should not have been tied to the chair. The DON and Administrator also confirmed that both residents should not have been restrained in any way, and the Administrator stated that a reasonable person restrained in that manner would have experienced psychosocial harm.
Failure to Immediately Report Unauthorized Restraints
Penalty
Summary
The facility failed to ensure staff reported alleged abuse involving the use of physical restraints to the administrator immediately or within 2 hours for two residents. The report states that staff found a sheet tied around each resident’s abdomen and secured behind the wheelchair, but the staff who observed the restraint did not immediately report the incidents to administration as required by facility policy. The policy reviewed by surveyors stated that any employee aware of an allegation of abuse, neglect, or misappropriation of resident property must report it to the Abuse Coordinator immediately. Resident #1 had a history of Alzheimer’s disease with late-onset dementia, cognitive communication deficit, major depressive disorder, anxiety disorder, schizophrenia, acute ischemic heart disease, and muscle wasting of both upper arms. A quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment. A CNA reported that she had recently placed a sheet around Resident #1’s abdomen and tied it to the wheelchair to secure the resident, and she did not immediately report that the resident had been restrained. Resident #2 had diagnoses including Alzheimer’s disease with late-onset, insomnia, cognitive communication deficit, impulsiveness, disorientation, major depressive disorder, and severe vascular dementia with agitation. An admission MDS showed a BIMS score of 0, indicating severe cognitive impairment. A CNA and an LPN reported that they saw Resident #2 restrained with a sheet tied around the abdomen and wheelchair, but they did not immediately report the restraint. The DON and Administrator confirmed that when residents were found restrained in this manner, the incidents should have been reported immediately and were not.
Failure to Provide Ordered Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary oral hygiene care as outlined in the care plan. The resident was admitted with diagnoses including sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, tracheostomy, and gastrostomy, and had an ADL self-care performance deficit related to cardiovascular accident and respiratory failure. The care plan specified an oral care routine in the morning and at night, including brushing teeth, cleaning gums with a toothette, and rinsing the mouth. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for oral hygiene. On observation, the resident was noted to have a tracheostomy and lips covered with white debris, and the respiratory therapist acknowledged that oral care was needed and stated that CNAs were responsible for providing oral care and that it should have been done. An LPN reported that she cared for the resident and that the resident did not receive oral care the previous day and was unsure how often CNAs provided oral care. A CNA stated she did not provide oral care because she believed the respiratory therapist did so. The ADON confirmed that oral care was in the resident’s plan of care, that CNAs were responsible for providing oral care every shift, and that the resident should have received oral care, demonstrating that the ordered oral hygiene interventions were not carried out as required.
Failure to Maintain Clean, Dry Conditions During Sacral Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with its own pressure injury prevention policy and professional standards of practice for a resident with a Stage 4 sacral pressure ulcer. The facility’s policy required residents to be kept clean and dry and to receive appropriate incontinent care as part of pressure injury prevention and treatment. The resident had multiple significant diagnoses, including multiple sclerosis, a Stage 4 sacral pressure ulcer, altered mental status, and hemiplegia/hemiparesis, and was documented as severely cognitively impaired and dependent on staff for toileting and personal hygiene. Physician orders and the resident’s care plan directed that the sacral area be cleaned with wound cleanser, Ioplex applied, and the area covered with a super absorbent dressing three times weekly and as needed if soiled. During an observed wound care treatment, the treatment nurse removed a saturated dressing from the resident’s sacral area and performed the ordered wound care while leaving a soiled brief in place. After completing the wound care and securing the new dressing, the nurse repositioned and secured the same soiled brief on the resident and replaced the bed linens without changing the brief. The treatment nurse acknowledged during interview that the brief was soiled during the wound care treatment. The DON later stated in interview that the soiled brief should have been changed prior to starting wound care and should not have been left on the resident after the wound care was completed.
Failure to Ensure Required Face-to-Face Physician Visits Every 60 Days
Penalty
Summary
The facility failed to ensure that a resident was seen face to face by a physician at least once every 60 days as required. Record review showed that the resident was admitted on 04/11/2025 with multiple serious diagnoses, including chronic respiratory failure, osteomyelitis of the lumbar vertebra, complete paraplegia, a sacral pressure ulcer, and a tracheostomy requiring ongoing attention. From admission on 04/11/2025 through discharge on 11/22/2025, the medical record contained documentation of only one face-to-face physician visit, dated 05/06/2025, with no additional face-to-face physician visits recorded for the remainder of the stay. During an interview on 01/06/2026 at 3:18 p.m., the DON confirmed that the resident had only one face-to-face physician visit during the entire period from admission to discharge and acknowledged that a face-to-face physician visit should have occurred every 60 days after the initial visit.
Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness, agitation, polyosteoarthritis, and schizoaffective disorder, did not receive required assistance with bathing. The resident was assessed as needing substantial to maximal assistance for bathing, meaning staff were expected to provide more than half the effort. Despite this, documentation for a two-week period showed no evidence that bathing was completed, with staff entering a code indicating 'not applicable' for bathing on multiple consecutive days. Interviews with the resident, CNAs, the DON, and a corporate nurse confirmed that the resident did not receive a bath during this period and that the 'not applicable' code was incorrectly used in place of proper documentation. The resident reported not receiving a bath for two weeks, and staff verified that the resident required assistance for bathing. The facility used a kiosk system for documenting care, which included an option for 'not applicable,' but this was not appropriate for the resident's needs. The failure to provide and document required ADL care for bathing led to the identified deficiency.
Failure to Monitor Edema in Resident Receiving Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for edema while the resident was receiving a diuretic. The resident, who had diagnoses including acute respiratory failure with hypoxia, pneumonia, acute kidney failure, and heart failure, was admitted with a care plan that required monitoring and documentation of any edema. Physician orders indicated the resident was to receive Furosemide 40mg twice daily for edema. However, a review of the February Medication Administration Record (MAR) showed no evidence that edema was monitored during this period. Both an LPN and a corporate nurse confirmed during interviews that the required monitoring for edema was not performed while the resident was on the diuretic.
Failure to Complete Skin Assessment and Report New Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and manage pressure ulcers for one resident. Specifically, a Certified Nursing Assistant (CNA) observed a red spot and a blister on the resident's bottom while preparing the resident for transfer to the hospital but did not report this new skin issue to the licensed nurse. As a result, the required notification of a change in skin status was not made, and the incident was not documented or addressed at the time it was discovered. Additionally, a head to toe assessment was not completed by the Licensed Practical Nurse (LPN) prior to the resident's discharge to the hospital, as required by the facility's Skin Integrity Prevention and Treatment Program Policy. The resident involved had a medical history including type 2 diabetes mellitus, an unspecified open wound on the right ankle, and dementia with behavioral disturbances. The care plan for this resident included monitoring for potential skin integrity impairment and reporting abnormalities, which was not followed in this instance.
Failure to Prevent Pressure Ulcers Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one of the residents reviewed. The facility's policy on pressure injury prevention included interventions such as turning and repositioning residents every two hours. However, there was no documented evidence that the nursing staff adhered to this policy for a resident with severe cognitive impairment and multiple medical conditions, including a history of fractures and dementia. The resident was re-admitted to the facility without any pressure ulcers, but a stage 2 pressure ulcer was later identified on the sacrum, indicating a failure in preventive care. The resident's care plan required turning and repositioning every two hours, but records showed no documentation of these actions on specific shifts over two days. Interviews with the Wound Care Nurse and the Director of Nursing confirmed the lack of documentation for the required care. This deficiency highlights a lapse in following the care plan and maintaining proper records, which are crucial for preventing pressure ulcers in residents with significant health challenges.
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown source with serious bodily injury within the required timeframe. The facility's Abuse Prohibition Policy mandates that such incidents be reported immediately or within 2 hours to the state agency. However, in this case, the incident was reported approximately 12 hours after the injury was identified. The resident, who had severe cognitive impairment and required assistance with daily activities, suffered a fall resulting in a right femur fracture. The incident occurred at 12:17 a.m., and the injury was confirmed by x-ray at 9:55 a.m., but the state agency was not notified until 10:16 p.m. The resident involved had a complex medical history, including severe cognitive impairment, chronic heart failure, and a history of fractures. After the fall, the resident exhibited signs of pain, prompting an x-ray that revealed the fracture. Despite the facility's policy, the administrator did not report the incident to the state agency within the required 2-hour window after being notified of the injury. This delay in reporting constitutes a deficiency in adhering to the facility's own policies and state regulations regarding the timely reporting of serious injuries.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The resident in question had a complex medical history, including severe cognitive impairment, multiple fractures, and other significant health conditions. Despite these needs, the care plan did not adequately address the necessary interventions, such as monitoring the cast on the right lower arm and using a stabilizer with an ace bandage on the right leg, ankle, and toes. The deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged that the facility did not implement the specified interventions on the care plan. This oversight was identified through a review of the resident's records, which showed no documented evidence of the interventions being carried out as required. The lack of implementation of these critical interventions highlights a failure in the facility's responsibility to provide appropriate care for the resident's complex medical needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents remained as free of accident hazards as possible, specifically for one resident who was reviewed for accidents. The facility did not complete fall risk assessments quarterly as required by their Fall Prevention Program Policy. The resident, who had a severe cognitive impairment and required assistance with activities of daily living, experienced a fall resulting in a right femur fracture. The facility's records showed that a fall risk assessment was not completed quarterly, with the last assessment done in April, prior to the fall in August. Interviews with facility staff revealed that specific interventions were not implemented for residents assessed to be at risk for falls, despite the facility's policy requiring such measures. The Corporate Nurse and Administrator confirmed that the facility did not have documented evidence of interventions being implemented when the resident returned from the hospital. Additionally, the facility did not follow its own policy and procedure for the Fall Prevention Program, as evidenced by the lack of a fall risk assessment on the specified date and the absence of specific interventions for the resident at risk.
Failure to Follow Incident Policy Leads to Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide care that maximizes the well-being of residents. This deficiency was evidenced by an incident involving a Certified Nurse Aide (CNA) who did not follow the facility's Incident/Accident policy when a resident was found on the floor. The policy required that the resident should not be moved until assessed by a licensed nurse, but the CNA assisted the resident back into bed before notifying the Licensed Practical Nurse (LPN). The resident involved had a complex medical history, including severe cognitive impairment, multiple fractures, heart failure, and other serious conditions. The resident was at risk for falls, and interventions were in place to mitigate this risk. However, the CNA's actions did not align with the established procedures, as she moved the resident without a nurse's assessment, potentially compromising the resident's safety. The Director of Nursing confirmed that the CNA's actions were not in accordance with the facility's policy.
Failure to Complete Discharge Assessment
Penalty
Summary
The facility failed to ensure a discharge assessment was completed for Resident #98 after being sent to an acute hospital. Record review revealed that Resident #98 was transported to the emergency room due to worsened wounds and abnormal vital signs. However, the Minimum Data Set (MDS) for Resident #98 did not include a discharge assessment following this hospitalization. During interviews, both the MDS RN and the Corporate Nurse confirmed that a discharge MDS should have been completed but was not.
Failure to Apply Splints as Ordered
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to increase or maintain their range of motion. Specifically, the facility did not apply splints as ordered for two residents. Resident #102, who has diagnoses including anoxic brain damage and muscle atrophy, had physician orders for bilateral hand splints to be applied daily. However, the documentation revealed that the splints were not applied on multiple dates in May 2024. Observations confirmed that the resident did not have the splints on during several checks, and a corporate nurse acknowledged the failure to follow the orders. Similarly, Resident #118, who has diagnoses including Parkinson's disease and muscle wasting, had orders for a right-hand splint to be applied daily. The documentation also showed that the splint was not applied on several dates in May 2024. Observations confirmed the absence of the splint during multiple checks, and an LPN confirmed that the splint should have been on but was not. The corporate nurse reviewed the clinical record and confirmed the lack of documentation for the splint application on the specified dates.
Failure to Change Enteral Feeding Container at Appropriate Interval
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding by not changing the enteral feeding container at the appropriate interval for one resident. The resident had multiple medical diagnoses, including cerebral infarction, facial weakness from a cerebrovascular accident, dysphagia, lack of coordination, and unspecified dementia. The physician's orders specified that the enteral feeding should be administered every night shift and the container should be changed every 24 hours. However, an observation revealed that the feeding tubing and container were dated four days prior, indicating they had not been changed as required. Interviews with the LPN, Corporate Nurse, and ADON confirmed that the enteral feeding should have been changed every 24 hours but was not.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews were completed at least every 12 months for three Certified Nursing Assistants (CNAs). Specifically, the personnel records for S5CNA, S6CNA, and S7CNA did not contain evidence of annual performance reviews. S5CNA was hired on 08/09/2022, S6CNA on 02/23/2023, and S7CNA on 02/28/2023. During an interview, the Administrator confirmed the absence of these performance reviews in the personnel records for the mentioned CNAs.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs of Resident #38 by not ensuring that the call light was within reach. Resident #38, who has a history of Alzheimer's disease, hypertension, chronic atrial fibrillation, seizures, intracerebral hemorrhage, cognitive communication deficit, major depressive disorder, and unspecified psychosis, was observed on multiple occasions with the call light on the floor behind the bed, out of reach. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 09, confirmed during an interview that he could not reach the call light. A CNA also observed and confirmed that the call light was not within the resident's reach, contrary to the care plan's directive to ensure the call light is accessible and to respond promptly to the resident's needs.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure garbage was disposed of properly. During an observation on 05/13/2024 at 8:40 a.m., multiple trash bags and loose trash were found scattered around the perimeter of the dumpster outside the facility. Additionally, the lids to the dumpster were not closed. In an interview conducted at 8:41 a.m. on the same day, the Maintenance Director confirmed that the trash should not be outside of the dumpster and that the dumpster lids should be closed.
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Illustrative
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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
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Nursing homes near Minden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town & Country Health & Rehab | 2 mi | ★★★★★ | 0 | 0 |
| Presbyterian Village Of Homer | 14.8 mi | ★★★★★ | 0 | 0 |
| Claiborne Rehabilitation | 20.6 mi | ★★★★★ | 3 | 0 |
| Ringgold Nursing And Rehabilitation Center, Llc | 20.9 mi | ★★★★★ | 1 | 0 |
| Willow Ridge Nursing And Rehabilitation Center,llc | 21.2 mi | ★★★★★ | 3 | 0 |
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