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 Meadowlake Estates during CMS and state inspections, most recent first.
Surveyors found a 100 mg gabapentin tablet lying unattended on top of a medication cart in a hallway with no staff in sight, contrary to facility policy requiring medications to be locked and not stored on top of the cart. The DON confirmed the pill was gabapentin and acknowledged a resident could have picked it up. An RN later reported that a gabapentin dose had been dropped during preparation for administration, could not be located, and that another tablet was given without notifying the DON or others, leaving the missing medication unsecured and accessible.
A resident with quadriplegia and multiple sclerosis was not bathed as scheduled, with documentation showing only one bath in January and none in February. The resident expressed frustration over missed showers, and staff interviews revealed inconsistencies in documenting completed or refused baths. The DON confirmed the lack of documentation for the resident's scheduled baths.
The facility failed to prevent and manage pressure ulcers for two residents. One resident developed a Stage II pressure ulcer due to inadequate incontinent care, while another's heels were not floated as per physician orders, risking further skin damage. The DON acknowledged lapses in care and communication.
A resident with dysphagia was given a brownie not suitable for their minced and moist level 5 diet, leading to a choking incident. The oversight occurred due to a new cook's error and lack of verification by staff. The resident's care plan was updated, and dietary staff were in-serviced on the importance of adhering to diet sheets.
The facility failed to ensure proper food storage and handling, leading to deficiencies such as improper storage of raw meat, presence of dented cans, expired food items, and inadequate labeling. Observations revealed that raw meat was not stored to prevent cross-contamination, dented cans were found in storage, and expired items were not removed. Additionally, food items were not properly labeled or sealed, contributing to the deficiencies.
The facility failed to adhere to infection control protocols during incontinent care, handling of linens, and PPE usage for COVID-19 positive residents. CNAs did not change gloves or sanitize hands appropriately, and a CMA entered a COVID-19 room without proper PPE. Additionally, a nurse handled medication with bare hands, violating the facility's policy.
The facility did not complete the MDS entry tracking for a resident as required by RAI guidelines. The resident's MDS list showed a discharge with a return anticipated, but no entry tracking record was completed. The clinical reimbursement specialist confirmed the resident went to the hospital and needed an entry, indicating non-compliance with RAI guidelines.
A resident with a history of seizures and traumatic brain injury was incorrectly documented as having died in the facility, despite being transferred to the hospital where they later expired. The DON confirmed the assessment was inaccurately coded, and the staff member responsible was no longer employed at the facility.
A resident with a UTI and cognitive impairment did not receive proper incontinent care, as a CNA failed to fully clean the resident's peri area before applying a new brief. Despite multiple attempts, the CNA left a brown substance on the resident's skin and brief, contrary to facility policy requiring thorough cleaning. The DON and LPN confirmed the expectation for staff to ensure residents are clean before placing a new brief.
A resident with chronic obstructive pulmonary disease received incorrect oxygen therapy at 3 liters per minute instead of the prescribed 2 liters per minute. The oxygen concentrator had significant dust buildup, and the filter was missing. The DON identified 24 residents receiving oxygen therapy, and RN #1 confirmed the incorrect dosage, adjusting it accordingly. Maintenance personnel were responsible for the concentrator filters, but cleaning frequency was uncertain.
The facility failed to remove expired medications from stock, as observed during a medication storage inspection. An expired magnesium chloride with calcium bottle was found, and staff interviews revealed inconsistent adherence to medication rotation processes. The DON confirmed that medications were supposed to be rotated to prevent expiration, indicating a lapse in medication management practices.
The facility failed to maintain the walk-in freezer in safe operating condition, affecting services for 106 residents. Significant ice buildup prevented the freezer door from sealing properly, with light visible from inside when closed. The CDM noted the issue had persisted for at least a year, with intermittent maintenance attempts. The DON could not locate a maintenance policy for the kitchen equipment.
The facility failed to complete discharge summaries for several residents, as required by their policy. The DON confirmed that the summaries were not completed, impacting residents discharged to other facilities, hospitals, and home with home health services.
The facility failed to provide adequate staffing, resulting in a resident not receiving timely incontinence care. Multiple staff members confirmed insufficient staffing, and the DON acknowledged the issue.
The facility failed to follow physician orders to provide diabetic residents with bedtime snacks and ensure snacks were served in accordance with residents' needs and preferences. Four residents reported rarely or never receiving their prescribed snacks, with one resident observing staff eating the residents' snacks. Resident council meeting forms also documented ongoing complaints about the lack of snacks provided.
The facility failed to ensure that residents' call lights were within reach for five residents, despite their varying levels of cognitive impairment and assistance needs. Observations showed call lights were often placed out of reach, and residents confirmed they could not access them until assisted by a CNA. Both RN and CNA staff acknowledged that call lights should be within reach, but this was not consistently ensured.
The facility failed to obtain signatures from the responsible party on the admissions agreements for a resident admitted with multiple diagnoses. The responsible party confirmed they were never asked to sign any admission paperwork, and the admission coordinator admitted that no signed consent to treat was available.
The facility failed to post nurse staffing information in a prominent area on halls 200, 300, 400, and 500 over several days. The DON confirmed that the information should have been posted daily. The facility had 114 residents at the time.
Unsecured Gabapentin Tablet Left Unattended on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to medication security when a white pill, later identified by the DON as a 100 mg gabapentin (an anticonvulsant), was observed lying on top of a medication cart in the hallway outside a resident's room with no staff in sight of the cart. Facility policy dated 01/2024 required that the medication cart be kept closed and locked when out of sight of the medication nurse, that no medications be kept on top of the cart, and that the cart be clearly visible to personnel when unlocked. The unattended pill on top of the cart was not stored in a locked compartment and was accessible in a common area. During interviews, the DON confirmed the pill was a 100 mg gabapentin and acknowledged that a resident could have picked up and consumed it. RN #1 reported that they had punched a 100 mg gabapentin pill from a card to administer to a resident, the pill dropped, and they were unable to locate it. RN #1 stated they obtained another pill and administered it to the resident without notifying the DON or anyone else about the missing medication. RN #1 also stated that another resident could have come by and taken the medication. The DON later stated that when RN #1 could not locate the missing medication, RN #1 should have notified someone to help look for it, and confirmed that the pill was found unattended and visible on top of the cart where another resident could have consumed it, meaning the medication was not stored to prevent unauthorized access.
Failure to Adhere to Bathing Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident was bathed as scheduled, which was identified during a survey. The resident, who was admitted with quadriplegia, multiple sclerosis, and muscle wasting, was dependent on staff for bathing and mobility. The resident's care plan indicated a preference for morning baths twice a week, on Wednesdays and Saturdays. However, documentation showed that the resident was bathed only once in January 2025, and there was no documentation for February 2025. The resident expressed frustration over missed showers and stated that staff did not offer to reschedule missed baths. Interviews with staff revealed inconsistencies in documenting completed or refused showers. A CNA acknowledged that all showers should be documented, and refusals should be recorded, but noted that the resident often refused baths. An LPN confirmed that refusals were not always documented as required. The DON admitted the absence of documentation for the resident's scheduled baths in January and February 2025, indicating a failure to adhere to the facility's bathing policy.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate incontinent care and adhere to physician orders, leading to the development and worsening of pressure ulcers in two residents. Resident #5, who was admitted with diagnoses including muscle wasting and major depressive disorder, was found to be soaking wet and developed a Stage II pressure ulcer on the sacrum due to moisture-associated skin damage. Despite a physician's order for hydrocolloid treatment three times weekly, the resident's condition was not adequately managed, resulting in a pressure wound. The Director of Nursing (DON) acknowledged that the resident should have been checked every two hours, and a Certified Nursing Assistant (CNA) was terminated as a result of this oversight. Resident #6, diagnosed with dementia and anxiety disorder, was observed multiple times with heels resting directly on the mattress, contrary to a physician's order to float the heels while in bed. This order, dated several months prior, was not followed, as the Licensed Practical Nurse (LPN) was unaware of it. The DON confirmed that physician orders should always be followed, indicating a lapse in communication and adherence to care protocols within the facility.
Failure to Follow Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to adhere to the prescribed minced and moist level 5 diet for a resident, which resulted in a choking incident. The resident, who had a physician's order for a minced and moist diet due to dysphagia and other medical conditions, was given a brownie that was not suitable for their dietary needs. This incident occurred while the resident was eating lunch in their room, and a medication aide noticed the resident choking, prompting a nurse to perform the Heimlich maneuver to expel the brownie. The incident report revealed that the dietary manager was notified, and it was determined that a new cook on the line had overlooked the resident's dietary restrictions. The dietary staff, including cooks and aides, were subsequently in-serviced on the importance of following diet sheets and ensuring residents receive the correct diet. The resident's care plan and plan of care were updated following the incident. Interviews with staff indicated a lack of awareness and verification of the resident's dietary needs at the time of the incident. The Assistant Director of Nursing (ADON) and other staff members acknowledged the oversight and emphasized the need for staff to check diet cards and ensure the correct diet is provided. The Director of Nursing (DON) also noted that speech therapy had not evaluated the resident, and there was reliance on hospital discharge reports for diet orders, which may have contributed to the oversight.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, leading to multiple deficiencies in the kitchen. Observations revealed that raw meat items were not stored in a manner to prevent cross-contamination, as different types of meat were placed together on a tray, and some pieces were hanging over the edges. Additionally, dented cans were found in the dry storage area, with some dents located in the seams, which could compromise the integrity of the cans. Expired food items, such as a container of salad dressing past its best-by date, were not removed from circulation, and leftover food items were not discarded within the appropriate timeframe, as evidenced by tartar sauce that should have been thrown away but was still present. Further issues included improper labeling and sealing of food items in the refrigerator, with grated Parmesan cheese left open to air and unlabeled cups of a dark material in the walk-in cooler. The facility's staff, including the CDM, acknowledged these lapses, noting that some staff members could not write English, which contributed to the labeling issues. The facility's policies on food storage, use of leftovers, and general food preparation were not consistently followed, as evidenced by the lack of proper dating and labeling of food items, and the failure to use a First In, First Out system effectively.
Infection Control and PPE Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide proper infection prevention and control measures during incontinent care and handling of linens for two residents. One resident was observed with a CNA whose hair fell into the brief and touched the resident during care. The CNA did not change gloves after handling soiled items and before touching clean items, such as the resident's pillow and quilt. Another resident was cared for by a CNA who did not change gloves or sanitize hands when transitioning from dirty to clean tasks, resulting in potential cross-contamination. Soiled linens were improperly handled, being placed on the floor instead of being bagged immediately. In the case of COVID-19 positive residents, the facility failed to ensure proper PPE usage. A CMA entered a COVID-19 positive resident's room without the required gown, gloves, face shield, or N95 mask, only wearing a standard face mask. Another CNA was observed wearing inadequate PPE while caring for two COVID-19 positive residents in the same room, failing to change PPE between residents. This CNA also did not wear a face shield or N95 mask, contrary to the facility's COVID-19 policy. Additionally, a nurse was observed handling medication with bare hands, contrary to the facility's medication administration policy, which requires gloves to be worn. The nurse admitted to not following the policy, acknowledging that gloves are a safety precaution meant to be used for all medication handling. These deficiencies highlight lapses in adherence to established infection control protocols, potentially compromising resident safety.
Failure to Complete MDS Entry Tracking per RAI Guidelines
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) entry tracking was completed according to the Resident Assessment Instrument (RAI) guidelines for a resident who was reviewed for assessments. The facility's Resident Assessment policy, revised in January 2020, mandates that assessment data be entered into a computerized format and transmitted to the Centers for Medicare & Medicaid Services (CMS) in a specified format. However, for one resident, the MDS list documented a discharge with a return anticipated, but there was no entry tracking record completed. On December 31, 2024, the clinical reimbursement specialist confirmed that the resident had gone to the hospital and required an entry, indicating that the RAI guidelines were not followed.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments, specifically for a resident with a history of seizures and traumatic brain injury. The deficiency was identified when a resident coded and was transferred to the hospital, where they eventually expired. However, the resident assessment inaccurately documented that the resident had died in the facility. This discrepancy was noted during a review of the resident's records, which included a nurse note and a transfer form indicating the resident was transferred to the hospital after emergency personnel restored their pulse. The Director of Nursing (DON) acknowledged the error, stating that the assessment was incorrectly coded as the resident did not die at the facility. The DON also mentioned that the staff member responsible for the incorrect assessment no longer worked at the facility. The facility's Resident Assessment policy requires each individual completing a portion of the assessment to certify its accuracy, which was not adhered to in this case, leading to the inaccurate documentation of the resident's status.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide proper incontinent care for a resident, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a diagnosis of UTI and moderate cognitive impairment, required substantial assistance for toilet hygiene and was always incontinent of bowel and bladder. During an observation, a CNA was seen providing peri care to the resident but failed to completely clean the resident's peri area, leaving a brown substance on the resident's skin and the new brief. Despite multiple attempts to clean the resident, the CNA did not ensure the resident was fully clean before placing a new brief. The facility's policy required staff to perform perineal care with each bath and after each incontinent episode, using a different wipe for each stroke and ensuring all urine and feces were removed before placing a clean brief. However, the CNA did not adhere to these guidelines, as evidenced by the incomplete cleaning observed. The DON and LPN confirmed that staff were expected to visually ensure residents were clean before applying a new brief, and acknowledged that there had been instances where staff needed reminders to complete incontinent care properly.
Oxygen Therapy Administration and Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered and that the oxygen concentrator was properly maintained for a resident with chronic obstructive pulmonary disease. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula, which could be removed for activities of daily living. However, observations revealed that the resident was receiving oxygen at 3 liters per minute, contrary to the physician's order. Additionally, the oxygen concentrator had significant dust buildup, and the filter was missing from the vent. The Director of Nursing (DON) identified 24 residents receiving oxygen therapy in the facility. During an interview, RN #1 confirmed that the resident was not receiving the correct oxygen dosage and adjusted it to the prescribed 2 liters per minute. The maintenance personnel were responsible for the concentrator filters, but there was uncertainty about the frequency of cleaning, which was suggested to be quarterly. The maintenance director and regional maintenance director confirmed the dust buildup and missing filter upon inspection of the concentrator.
Failure to Remove Expired Medications from Stock
Penalty
Summary
The facility failed to ensure that outdated medications were removed from stock, as observed during a medication storage inspection. A bottle of magnesium chloride with calcium was found to be expired, with a best by date that had already passed. The Assistant Director of Nursing (ADON) confirmed that all 111 residents in the facility were administered medications by the nursing staff. During the inspection, it was noted that the facility's medication storage policy required outdated, contaminated, discontinued, or deteriorated medications to be immediately removed from stock. However, this policy was not adhered to, as evidenced by the expired medication found. Interviews with the staff revealed a lack of consistent adherence to the medication rotation process. ACMA #2 acknowledged that someone was supposed to check expiration dates and rotate stock, but the expired medication was still present. CMA #3 expressed surprise at the expired medication, stating that they had last checked the medications on a previous date and had attempted to rotate stock by placing new medications at the back. However, they admitted that the expired magnesium might have been overlooked if it had fallen behind or under the cart. Additionally, a vitamin E bottle was found improperly rotated, with an older expiration date placed behind a newer one. The Director of Nursing (DON) confirmed that medications were supposed to be rotated to prevent expiration, indicating a lapse in the facility's medication management practices.
Walk-in Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the walk-in freezer was in safe operating condition, affecting the services provided to 106 residents. During an observation, the walk-in cooler's internal temperature was noted to be 34.7 degrees. The entrance to the walk-in freezer, located inside the cooler, exhibited significant ice buildup on the doorway, preventing the door from sealing properly. Light was visible from inside the freezer with the door closed, and icicles of varying sizes were observed on the shelving inside the freezer. A large clump of ice was found on the middle shelf, and ice covered the floor at the entrance. The Certified Dietary Manager (CDM) mentioned that the freezer door was supposed to have a heater, but due to its age, it had been malfunctioning for at least a year. The CDM stated that maintenance personnel had been addressing the issue intermittently by using a hammer to remove ice so the door could close properly. The last maintenance work on the freezer was reported to have occurred the previous month. The Director of Nursing (DON) was unable to locate a maintenance policy for the kitchen equipment.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure a discharge summary was completed for five residents reviewed for discharge summaries. The facility's policy, revised on 01/12/202, mandates that a recapitulation summary should be completed within 20 days of the date of discharge to ensure necessary information is communicated to the resident and the receiving health care provider. However, for residents #41, 44, 99, and #115, there was no documentation that a discharge summary had been completed. The Director of Nursing (DON) confirmed that if the discharge summary is blank in the Electronic Health Record (EHR), it indicates that a discharge summary was not completed. The MDS coordinator was identified as the person responsible for completing the discharge summaries. Resident #41, admitted with multiple diagnoses including diabetes mellitus and chronic pain, was discharged to another facility without a completed discharge summary. Resident #44, with diagnoses such as UTI and atrial fibrillation, was discharged to the hospital without a discharge summary. Resident #99, with chronic pain syndrome and diabetes, was discharged to home with home health services, and Resident #115, with CVA and diabetes, was also discharged to home with home health services, both without completed discharge summaries. The lack of discharge summaries for these residents indicates a failure to adhere to the facility's policy and ensure proper communication of necessary information at the time of discharge.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to provide adequate staffing on a 24-hour basis to meet the needs of its residents, as evidenced by the case of one resident who required substantial assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. The resident reported that no one had changed their brief since 9:00 p.m. the previous night, and when they turned on their call light, CNAs would turn it off and say they would return but often did not. The resident had to call the Director of Nursing (DON) at home to receive care. Daily staffing sheets from 01/26/24 to 02/13/24 documented that 27 of 57 shifts did not meet the staffing ratio requirements for the facility census. Multiple CNAs confirmed that they had not checked on the resident that day, despite the facility's policy requiring checks every one to two hours. Additionally, both an RN and an LPN reported that they did not always have adequate staff on the 11 p.m. to 7 a.m. shift, and a CNA reported insufficient staffing on the 7 a.m. to 3 p.m. shift. The DON acknowledged the issue of insufficient staffing and stated that it was the staffing coordinator's responsibility to ensure adequate staffing to meet residents' needs.
Failure to Provide Prescribed Bedtime Snacks to Diabetic Residents
Penalty
Summary
The facility failed to follow physician orders to provide diabetic residents with a bedtime (HS) snack and ensure snacks were served to all residents at times in accordance with their needs, preferences, and requests. This deficiency was observed in four residents diagnosed with diabetes mellitus. Resident #18, #26, #32, and #38 all reported that they rarely or never received their prescribed bedtime snacks. Resident #26 additionally reported having to go into the hall to ask for a snack, often finding none left, and observed staff eating the residents' snacks. The facility's policy, dated 08/01/2018, required that snacks and supplements be prepared and available to residents three times daily, including a variety of foods for HS snacks, but this was not adhered to in practice. The deficiency was further corroborated by resident council meeting forms from August, September, and December 2023, which documented complaints about the lack of snacks being provided, particularly to diabetic residents. The Dietary Manager (DM) confirmed that snacks were prepared at 10 a.m., 2 p.m., and around 7 p.m., but did not specify any particular provisions for diabetic residents beyond offering fruit, sandwiches, and cake without icing. The Director of Nursing (DON) was unaware that residents were not being offered bedtime snacks until informed during the survey.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach for five sampled residents. Resident #3, who had severe cognitive impairment and required substantial assistance with most ADLs, was observed multiple times with their call light hanging from the wall at the end of their bed, out of reach. Similarly, Resident #5, with moderate cognitive impairment and requiring substantial assistance with ADLs, was also observed with their call light hanging from the wall between the wall and the end of their bed, making it inaccessible. Both residents confirmed they could not reach their call lights until a CNA handed them the device, after which they demonstrated how to use it. Resident #21, with severe cognitive impairment and limited assistance needs for ADLs, was observed multiple times with their call light hanging from the wall at the end of their bed, out of reach. The resident confirmed they could not reach their call light and demonstrated its use once it was handed to them. Resident #50, with intact cognition and moderate assistance needs for ADLs, was observed with their call light hanging from the wall and later underneath the bed, making it inaccessible. The resident confirmed they could not reach their call light until it was handed to them by a CNA. Resident #64, with moderate cognitive impairment and requiring moderate assistance with ADLs, was observed with their call light in the top drawer of their bedside table, which was closed on the call light, making it inaccessible. The resident confirmed they could not reach their call light until it was handed to them by a CNA. Both the RN and CNA interviewed stated that call lights should be within residents' reach, but observations showed this was not consistently ensured. The DON was made aware of these findings and acknowledged that call lights should be within residents' reach at all times.
Failure to Obtain Signatures on Admission Agreements
Penalty
Summary
The facility failed to obtain signatures from the responsible party on the admissions agreements for a resident. The resident was admitted with diagnoses including atrial fibrillation, UTI, hyponatremia, CVA, and bulimia. The facility's admission packet included various forms such as patient information, consent forms, and the resident admission agreement. However, the responsible party for the resident stated during a phone interview that they were never asked to sign any admission paperwork at the time of admission or afterward. No admission paperwork was found in the clinical record for this resident. The admission coordinator confirmed that their procedure involved conducting admission paperwork either in the facility or by emailing the packet to the resident's responsible party. When asked specifically about the signed consent to treat for the resident, the admission coordinator admitted that they did not have it. This failure to obtain the necessary signatures on the admission agreements was identified during the survey, highlighting a deficiency in the facility's admission process.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. This deficiency was observed on halls 200, 300, 400, and 500 from 02/13/23 through 02/16/23. The Director of Nursing (DON) confirmed that the nurse staffing information should have been posted in a prominent area daily. The facility had 114 residents at the time of the survey.
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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.
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Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookwood Skilled Nursing And Therapy | 1.6 mi | ★★★★★ | 8 | 0 |
| Accel At Crystal Park | 2.1 mi | ★★★★★ | 10 | 1 |
| Thunder Care And Rehabilitation | 2.3 mi | ★★★★★ | 4 | 0 |
| Emerald Care Center Southwest Llc | 3.5 mi | ★★★★★ | 1 | 0 |
| Capitol Hill Skilled Nursing And Therapy | 3.7 mi | ★★★★★ | 0 | 0 |
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