Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Meadowbrook Care Center during CMS and state inspections, most recent first.
Failure to Protect Two Residents from Physical Abuse: Two residents became involved in an altercation when their wheelchairs became entangled in the doorway of one resident's room. One resident grabbed the other resident's arm while they argued about entering the room. Both residents had moderate cognitive impairment, and the incident was classified as abuse after the DON, administrator, and police reviewed the event.
A resident with muscle weakness, unsteady gait, osteoporosis, cognitive impairment, and a high fall risk required assistance with transfers and had been recommended for sit-to-stand mechanical lift use and gait belt support. The care plan and medical record contained only general language about assistance and transfer aids and did not clearly specify the exact transfer method or device to be used. Despite knowing the resident’s transfer status and prior use of a sit-to-stand lift, a CNA attempted a bed-to-wheelchair transfer using only her hands, without a gait belt or mechanical lift, during which the resident’s knee gave out and she ended up kneeling on the floor, later found to have a left hip fracture. Staff interviews confirmed that transfer aids should have been used and that there was no documentation of the resident refusing the sit-to-stand, while the DON acknowledged not following up on therapy’s recommendation to formalize and implement the sit-to-stand transfer in the resident’s plan of care.
The facility failed to ensure that comprehensive MDS assessments accurately reflected the use of mechanical lifts and sit-to-stand devices for multiple residents with muscle weakness, unsteadiness, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting. Several residents reported being transferred with machines, and surveyors observed CNAs using Hoyer lifts and sit-to-stand devices, yet the corresponding MDS assessments did not code mechanical lift use, and physician orders were absent. Care plans either referenced mechanical lifts without matching orders or mentioned only generic adaptive equipment without specifying transfer aids, despite residents requiring staff assistance for transfers and ADLs.
The facility failed to develop and implement comprehensive, person-centered care plans that specified the use of mechanical lifts for several residents with muscle weakness, unsteadiness, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting. Although some residents reported being transferred with a machine and surveyors observed CNAs using a sit-to-stand device, the MDS assessments did not document mechanical lift use, the care plans only referenced generic adaptive equipment or assistance with transfers, and there were no corresponding physician orders for sit-to-stand or Hoyer lifts. This resulted in residents receiving transfers via mechanical lifts that were not clearly identified or individualized in their care plans as required by facility policy.
A deficiency was cited for not ensuring a resident's right to a safe, clean, comfortable, and homelike environment, including the safe provision of daily living supports and treatments.
Surveyors found that the facility failed to properly store, label, and seal food items, did not discard expired foods, and did not maintain cleanliness of kitchen equipment and areas. Observations included unlabeled and unsealed food in refrigerators and freezers, expired items in dry storage, dirty equipment, and a trashcan without a lid, all contrary to facility policy and FDA standards.
Staff did not ensure the privacy and confidentiality of a resident's personal and medical records, resulting in unauthorized access or exposure of sensitive information.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a history of repeated falls, dementia, and quadriplegia was found in bed without the required fall mat in place, as specified in the care plan. The fall mat was observed folded at the foot of the bed, and staff interviews confirmed it should have been positioned alongside the bed to prevent injury. This failure resulted in the environment not being free from accident hazards as required.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the actions or events that led to this failure.
A resident with COPD receiving oxygen therapy and as-needed nebulized medication had their t-tube left unbagged on a side table for an extended period, contrary to facility policy and infection control standards. Staff did not notice or address the improper storage during rounds, and there was no sign posted to indicate oxygen use outside the room.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with moderate cognitive impairment and multiple health issues did not receive necessary dental services due to a lack of coordination among facility staff. Despite a care plan indicating the need for a dental consult, the referral was not made, leading to poor oral health. Interviews revealed that the ADON, MDS nurse, and SW were not aligned on responsibilities, resulting in the resident's unmet dental needs.
A resident with severe cognitive impairment and incontinence issues was subject to improper infection control practices by two CNAs during incontinent care. The CNAs placed soiled wipes on the resident's brief and used bed padding on top of a new, clean brief, contrary to infection control protocols. This failure was acknowledged by the CNAs and confirmed by facility staff, highlighting a deficiency in maintaining a safe and sanitary environment.
Failure to Protect Two Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when Resident #1 grabbed Resident #2's right arm during an altercation in the doorway of Resident #1's room. The incident occurred when the residents' wheelchairs became entangled, and the report states that Resident #1 grabbed Resident #2 while they were arguing about Resident #2 entering the room. The incident was categorized as abuse in the Provider Investigation Report dated 04/01/2026. Resident #1 was a female with diagnoses including cerebral infarction, depression, and hypertension. Her quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and her care plan noted impaired cognition or thought processes related to difficulty making decisions. The investigation report stated that Resident #1 had no injuries, marks, or bruises from the incident. During the administrator and police interview, Resident #1 said Resident #2 tried to enter her room, yelled obscenities, and moved toward the doorway, and that she grabbed Resident #2's arm to stop her from entering. Resident #2 was a female with diagnoses including Alzheimer's disease, mood disorder, insomnia, and high blood pressure. Her MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and her care plan addressed communication problems related to dementia. The investigation report stated that after the incident the residents were separated and Resident #2 was moved to another room on the other side of the facility. A head-to-toe assessment found no injuries, marks, or bruises, and the administrator and police interview noted that Resident #2 could not clearly describe what happened because of her cognitive impairment.
Failure to Use Ordered Transfer Aids Resulting in Resident Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents, specifically for one resident. The resident was a 78-year-old female with diagnoses including muscle weakness, unsteadiness of feet, lack of coordination, convulsions, osteoporosis, and a history of falls. Her MDS showed moderate cognitive impairment and a need for partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. She was identified as high risk for falls, and the NP had ordered strict fall precautions due to impaired balance. Despite these risk factors, her comprehensive care plans only generally stated that she would receive assistance with transfers and ambulation and would use adaptive equipment such as transfer aids, but they did not specify the exact mode of transfer or required transfer device. There was no physician order detailing how she should be transferred. On the day of the incident, CNA A attempted to transfer the resident from bed to wheelchair without using any transfer aid such as a gait belt or sit-to-stand lift. Multiple staff interviews confirmed that the resident’s mode of transfer had been changed from stand-and-pivot to use of a sit-to-stand mechanical lift due to weakness, and that staff, including CNA A, were aware of this recommendation and had previously used the sit-to-stand with the resident. CNA A acknowledged knowing the resident was a sit-to-stand transfer and admitted she did not use the sit-to-stand on the day of the fall. RN B and the Weekend Supervisor both stated that if the resident was a one-person assist, a gait belt should have been used, and that transfer aids such as gait belts and mechanical lifts were expected for safety. RN B reported seeing the gait belt hanging on the wall unused when she entered the room after the incident. During the transfer, the resident lost her balance; staff reported that one of her knees gave out and she ended up kneeling on the floor beside the bed, with her upper body leaning on the bed. The resident complained of severe left hip pain rated 10/10 and requested to be sent to the hospital. She later reported that CNA A did not use a gait belt or a machine, while other CNAs did use a machine when transferring her. The DON and other staff confirmed that prior to the incident the resident was considered a one-person assist and that staff were supposed to use a gait belt and, if ordered, the sit-to-stand lift. The DON also acknowledged that therapy had recommended changing the resident’s mode of transfer to sit-to-stand and that she failed to follow up on whether this recommendation was finalized and implemented. There was no documentation that the resident refused the sit-to-stand prior to the fall. The combination of an unclear, nonspecific care plan, lack of a specific transfer order, failure to follow therapy’s transfer recommendations, and CNA A’s failure to use the required transfer aid during the transfer led to the fall and subsequent left hip fracture. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents constituted noncompliance with F689 and resulted in an Immediate Jeopardy situation. The incident showed that the resident, who had multiple fall and fracture risk factors and was on strict fall precautions, was transferred without the prescribed or expected transfer aids, and that the facility had not ensured that the care plan and medical record clearly and specifically directed staff on the resident’s required mode of transfer. Interviews with multiple staff members revealed inconsistent understanding and implementation of the resident’s transfer status and highlighted that, at the time of the incident, the resident’s transfer needs were not consistently communicated or followed, directly contributing to the accident.
Removal Plan
- Resident #1 evaluated by nursing staff
- Resident #1 care plan updated to reflect current transfer status (requires sit-to-stand lift)
- Order placed in the electronic medical record for mechanical lift transfers for Resident #1
- Physical Therapy referral placed in the electronic medical record for evaluation and treatment for Resident #1
- All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy prior to working their next shift (including telephone education for absent staff)
- All new hires and agency staff to receive Safe Resident Handling/Transfers policy education before providing resident care
- 1:1 education provided to the Director of Nursing on following therapy recommendations for resident transfers and discussing transfer needs in clinical meetings and Standards of Care meetings
- DON/designee reassessed all residents using the Fall Risk Assessment Tool
- MDS/MOS nurse ensured all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans
- MDS/MOS nurse ensured added safety measures/interventions were reflected in both electronic and paper medical records so CNAs had access
- DON/designee instructed CNAs to review the updated paper medical record prior to their next shift
- Audit of all residents requiring assistance with transfers to ensure accuracy of transfer status and updated care plans
- Audit of all therapy recommendations to ensure they were reviewed and followed
- Safe Resident Handling/Transfers policy reviewed
- DON/designee to audit new admissions daily to ensure Fall Risk Assessment completion and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan and updated on the Kardex
- Regional Nurse Consultant to review all falls within 72 hours to ensure an RCA is conducted and resident-specific interventions are reflected in the care plan and updated in paper/electronic care plans
- DON/designee to review all falls at the daily stand-up meeting with the IDT to ensure appropriate fall interventions are implemented, the care plan is reviewed/revised, and the Kardex is updated
- Interdisciplinary team to review all audit results in QAPI with additional training provided if trends are identified
- Medical Director notified of the deficient practice/Immediate Jeopardy and the Plan of Removal
Inaccurate MDS Coding of Mechanical Lift Use for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that comprehensive MDS assessments accurately reflected the use of mechanical lifts for eight residents out of twenty-nine reviewed. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the corresponding Comprehensive MDS Assessments did not indicate that mechanical lifts or sit-to-stand devices were being used, despite other evidence that these devices were part of their care. The MDS Nurse stated she did not code the use of mechanical lifts because she did not see physician orders for these devices, even though she acknowledged that the MDS is a tool to identify resident care needs and provide an overall picture of the resident. For one resident with moderate cognitive impairment and a history of falls, the Comprehensive MDS Assessment did not show mechanical lift use, and the care plan referenced adaptive equipment for ADLs without specifying the transfer aid. The resident reported that some staff transferred her using a machine and that she had used it the previous year. Another cognitively intact resident with muscle weakness and lack of coordination had a care plan intervention specifying assistance with transfers via mechanical lift as needed, but the MDS did not reflect mechanical lift use and there was no physician order for a mechanical lift. A third cognitively intact resident with similar diagnoses had a care plan directing transfer with a Hoyer lift to a wheelchair; however, the MDS did not indicate mechanical lift use and there was no physician order, even though the resident described being transferred with a machine and surveyors observed CNAs using a Hoyer lift and sling to transfer her. Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, unsteadiness of feet, lack of coordination, multiple sclerosis, contractures, and muscle wasting also had Comprehensive MDS Assessments that did not indicate mechanical lift or sit-to-stand use. Their care plans either did not specify the type of transfer aid or did not include Hoyer lift interventions, and physician orders for mechanical lifts or sit-to-stand devices were absent. One resident reported beginning to use a sit-to-stand device when his legs became weaker, and surveyors observed CNAs transferring him with a sit-to-stand machine, yet his MDS did not reflect this mode of transfer and there was no corresponding order. The facility’s written policy on comprehensive assessment required gathering relevant information from multiple sources, including observation, physical assessment, and resident interview, to conduct comprehensive assessments and develop person-centered care plans, but the assessments reviewed did not accurately capture the residents’ actual transfer methods involving mechanical lifts.
Failure to Care Plan and Order Specific Mechanical Lift Transfer Modes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans that included specific, measurable objectives and timeframes for residents’ transfer needs, particularly the use of mechanical lifts. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the comprehensive MDS assessments did not indicate the use of mechanical lifts. Despite these conditions and histories of falls, the residents’ care plans either generically referenced adaptive equipment or assistance with transfers without specifying the type of transfer aid or mechanical lift to be used. For one resident with moderate cognitive impairment and a history of falls, the care plan identified fall risk and referenced adaptive equipment but did not specify the transfer aid, and there was no physician order for a sit-to-stand device, even though the resident reported that some staff transferred her using a machine. Another resident with severe cognitive impairment and lower extremity weakness had a care plan that stated he would be assisted with transfers and use adaptive equipment, but it did not identify the specific transfer aid, and there was no physician order for a sit-to-stand, despite the resident stating he began using a sit-to-stand device when his legs became weaker. Surveyor observation confirmed CNAs using a sit-to-stand machine to transfer this resident to a wheelchair. Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, lack of coordination, multiple sclerosis, contractures, and muscle wasting were not care planned for the specific use of Hoyer lifts or other mechanical lifts, and their physician orders did not include these devices. Their care plans referenced varying levels of staff assistance for ADLs and the use of adaptive equipment but did not identify the specific transfer mode or mechanical lift in use. Facility policy required comprehensive person-centered care plans with measurable objectives and timeframes to meet residents’ needs as identified in the comprehensive assessment, but the care plans for these residents did not reflect the specific transfer needs or mechanical lift use that was being provided.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's only kitchen regarding food storage, preparation, and sanitation practices. Specifically, a trashcan in the dining room was found without a lid, exposing contents to air-borne contaminants. The dining room also contained a large air vent with visible stains, a microwave with brownish stains, and a serving cart with food particles and trash. In the refrigerator, a zip-locked bag of fruit and a gallon of Asian Sesame Dressing were not labeled with storage dates. In the freezer, a box of French toast and a box of frozen waffles were not sealed, and a bag of frozen ground beef was not labeled with the date it was stored. An ice scoop was left uncovered, and its holder was dirty. Expired food items, such as flour tortillas and frozen biscuits, were not discarded, and a refrigerator in the dry storage area had black stains inside. Interviews with the Dietary Manager revealed that while there was a cleaning schedule in place, some tasks, such as replacing trashcan lids and labeling food, were not consistently performed, especially when new staff were involved. The Dietary Manager acknowledged responsibility for ensuring food safety practices but admitted to lapses due to oversight and new staff still learning procedures. The Administrator confirmed awareness of the issues and stated expectations for cleanliness and proper food handling. Facility policies and FDA guidelines reviewed by surveyors required proper labeling, dating, sealing, and sanitation of food and equipment, which were not followed as observed.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential. This deficiency occurred when staff did not maintain the required level of privacy for sensitive information, resulting in unauthorized access or exposure of residents' records.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Ensure Fall Mat Placement for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with a history of repeated falls, dementia, and quadriplegia was observed without a fall mat placed alongside his bed, as required by his care plan. The resident's care plan specifically included the intervention of ensuring a fall mat was positioned next to the bed to prevent injury from falls. During an observation, the fall mat was found folded and leaning against the foot of the bed while the resident was lying in bed, and a bedside table was positioned over him. Interviews with the ADON and DON confirmed that the fall mat should have been in place while the resident was in bed, as he was considered a fall risk. Both staff members indicated that Hospice staff may have forgotten to reposition the fall mat after providing care. The facility's policy on fall management requires identification of residents at risk for falls and implementation of interventions, such as the use of a fall mat, to manage those risks. The failure to ensure the fall mat was in place constituted a lapse in maintaining an environment free from accident hazards for the resident.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No additional information about the medical history or condition of any resident at the time of the deficiency is provided in the report.
Failure to Properly Store Respiratory Equipment and Indicate Oxygen Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) who required oxygen therapy and as-needed breathing treatments. Observations revealed that the resident's t-tube, used for nebulized medication administration, was left unbagged on the side table after its last use, which was reportedly a week prior to the survey. Both the resident and staff confirmed that the t-tube was not stored in a clean plastic bag as required by facility policy and professional standards, and staff did not notice or address the improper storage during routine rounds. Additionally, there was no sign posted outside the resident's room to indicate that oxygen was in use, as required for safety precautions. Interviews with nursing staff and facility leadership confirmed that the expectation was for all respiratory equipment to be properly cleaned and stored in a plastic bag when not in use, and that the lack of proper storage could not be accounted for. Review of facility policy confirmed the requirement for infection control practices and proper handling and storage of respiratory equipment.
Improper Storage and Labeling of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a deficiency related to the storage and labeling of medications and biologicals within the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Coordinate Dental Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, which was identified during a survey. The resident, a female with moderate cognitive impairment and multiple health issues including stroke, dementia, and malnutrition, was dependent on staff for oral care. Her care plan, revised in March, indicated the need for a dental consult due to oral/dental problems. However, the facility did not follow through with this referral, as evidenced by the resident's poor oral condition observed during the survey. Interviews with facility staff revealed a lack of communication and responsibility regarding the dental referral. The Assistant Director of Nursing (ADON) was unaware of the resident's care plan for a dental consult, and the MDS nurse assumed the Social Worker (SW) would handle the referral. The SW, who had been working part-time, was not informed of the need for a dental referral for the resident. The facility's policy stated that the Social Services department or designee was responsible for coordinating ancillary services, but this process was not effectively implemented, resulting in the resident not receiving the necessary dental care.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, which resulted in a deficiency related to the care of a resident with severe cognitive impairment and incontinence issues. During an observation, two CNAs were preparing the resident for a doctor's appointment and were performing incontinent care. Despite washing their hands and changing gloves, the CNAs placed soiled wipes on the resident's brief, and the used bed padding was placed on top of a new, clean brief. This action was contrary to proper infection control practices and could lead to cross-contamination. The resident involved was an elderly female with a history of diarrhea and urinary incontinence, requiring assistance with activities of daily living. The CNAs, while performing perineal care, did not follow the correct procedure of removing soiled items before placing clean ones. This oversight was acknowledged by both CNAs during interviews, where they admitted that the soiled padding should not have been placed on the clean brief, as it could lead to the transfer of germs and potential infections. Interviews with the RN, Interim DON, ADON, and Administrator confirmed that the correct procedure was not followed, emphasizing the importance of separating clean and soiled items to prevent infections. The facility's procedure for perineal care also highlighted the need to dispose of soiled articles to promote cleanliness and prevent infection, which was not adhered to in this instance.
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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 Van Alstyne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Hollow Rehabilitation Center | 11.2 mi | ★★★★★ | 7 | 2 |
| Settlers Ridge Care Center | 12.3 mi | ★★★★★ | 1 | 0 |
| Focused Care At Sherman | 14.3 mi | ★★★★★ | 3 | 0 |
| North Park Health And Rehabilitation Center | 14.4 mi | ★★★★★ | 0 | 0 |
| Park Manor Of Mckinney | 14.8 mi | ★★★★★ | 0 | 0 |
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