Inspection·May 19, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately notify the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was an accident involving the resident for 1 of 7 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's physician and representative were notified after Resident #1 had a fall. This failure could result in the family or guardian not being aware of conditions that may require them to make medical decisions. Findings included: Record review of a facility face sheet dated 5/15/25 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease (condition caused by the buildup of plaque in the arteries, leading to reduced blood flow and increasing the risk for heart attacks and strokes), atrial flutter (abnormal heart rhythm), hypertension (high blood pressure), and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that he had a BIMS score of 6, indicating he had severely impaired cognition. Resident was occasionally incontinent of urine and always incontinent of bowel. Record review of a comprehensive care plan dated 5/10/25 for Resident #1 indicated he had an actual fall on 5/10/25 which resulted in a bruise on his forehead related to unsteady gait. Interventions included: determine and address causative factors of the fall, provide activities that promote exercise and strength building where possible. Record review of a progress note dated 5/10/25 at 8:00 p.m. and signed by LVN A indicated the following: Resident observed on floor in room beside his bed. Vital signs wnl and neuro checks wnl. Resident assisted from floor to bed per this nurse and one staff member. Resident was dressed in non-skid socks at the time. Prior to fall resident was laying in the bed in his room. Resident observed resting in bed prior to fall. Resident assisted from floor to wheelchair X2 staff. Staff continued to monitor resident. During an interview on 5/15/25 at 10:00 a.m. the DON said Resident #1 had a fall and LVN A did not (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 05/19/2025 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)