F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for each resident that included measurable objectives and time frames to meet a resident's
medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #15) reviewed for care
plans.
The facility failed to ensure Resident #15's care plan reflected diagnoses of infections and the physician's
orders for antibiotic therapy.
This failure could place residents at risk of not receiving care and services to meet medical and nursing
needs.
The findings included:
Record review of a face sheet dated 08/20/24 indicated Resident #15 was an [AGE] year-old female who
admitted to the facility on [DATE] with diagnoses of subdural hemorrhage (bleeding between the brain and
the skull), dementia, diabetes mellitus, and MSSA (methicillin-sensitive-staphylococcus aureus) bacteremia
(an infection caused by MSSA entering the bloodstream). Diagnoses of urinary tract infection, pneumonia,
and obstructive and reflux uropathy (disorder of the urinary tract that obstructs urine flow) were added to
the diagnosis list on 01/24/2024. Record review of an MDS quarterly assessment dated [DATE] indicated
Resident #15 had a BIMS score of 7 (severely impaired cognition), was incontinent of bowel and bladder,
and required substantial to maximum assistance with bathing and hygiene care.
Record review of Resident #15's MDS (Section I: Active Diagnoses) dated 04/05/2024 indicated Resident
#15 had diagnoses of pneumonia and a urinary tract infection.
Record review of Resident #15's MDS (Section N :High Risk Drug Classes) dated 07/06/2024 indicated
Resident #15 was receiving an antibiotic with an indication for use.
Record review of laboratory results of urine testing on 02/27/2024, 03/29/2024, and 04/26/2024 indicated
Resident #15 tested positive for urinary tract infections on all 3 (three) dates.
Record review of Resident #15's physician orders since admission indicated Resident #15 had orders
dated 02/27/2024 for the antibiotic Macrobid, 02/28/2024 for the antibiotic Cipro, and 03/30/2024 for the
antibiotic Omnicef to treat urinary tract infections. An order dated 05/02/2024 indicated Resident #15 was to
receive Keflex (an antibiotic) 3 (three) days a week for prophylactic treatment of
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676286
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676286
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadow Lake Health Center
16044 County Road 165
Tyler, TX 75703
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
urinary tract infections on an ongoing basis.
Level of Harm - Minimal harm
or potential for actual harm
Record review of a Medication Administration Record dated August, 2024 indicated Resident #15 was
receiving Keflex 3 (three) days a week on Monday, Wednesday, and Friday.
Residents Affected - Few
Record review of Resident #15's Care Plan dated 08/20/24 indicated the comprehensive care plan was
initiated on 01/31/2024 and had not been updated to include actions/interventions to address Resident
#15's diagnoses of pneumonia and urinary tract infections nor antibiotic usage since admission. The care
plan did not include any concerns nor interventions to address Resident #15's risk for urinary tract infection,
actual urinary tract infections, nor past or current use of ongoing prophylactic use of an antibiotic.
During an interview with the DON at 03:30 PM on 08/20/2024, he said care plans were completed on
admission and updated at least quarterly and as needed. He said Resident #15's care plan should have
addressed each of the infections she had incurred and should have been updated to address Resident
#15's current antibiotic therapy. The DON said the failure to address these issues in the care plan was an
oversight. The DON said the care plans were individualized to each resident and it was important to keep
the care plans updated and accurate to ensure a resident's needs and interventions to meet those needs
were communicated. He said everyone on the interdisciplinary care plan team was responsible for ensuring
care plans were complete.
A review of the facility's policy titled Comprehensive Care Plan indicated the following:
Procedures
8. The comprehensive, person-centered care plan will:
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable
physical, mental, and psychosocial well-being,
g. Incorporate identified problem areas,
h. Incorporate risk factors associated with identified problems,
13. Assessments of residents are ongoing and care plans are revised as information about the residents
and the residents' conditions change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676286
If continuation sheet
Page 2 of 2
