Meadowood Nursing Center: Resident Abuse Ignored - CA
That is what inspectors found when they visited Meadowood Nursing Center at 3805 Dexter Lane in late April 2026. The complaint inspection, completed April 30, documented a resident-to-resident incident that the facility's own social service director and assistant director of nursing both characterized as physical and verbal abuse — abuse that staff witnessed and did not stop.
The incident began at the nurse's station. Resident 1 had rolled up in her wheelchair calling for her nurse. Resident 2 was already there, seated in her own wheelchair. According to CNA 1, who was present, Resident 2 yelled at Resident 1 to go away. Then Resident 2 kicked Resident 1 in the knee.
CNA 1 confirmed the kick was intentional. She told inspectors, "[Resident 2] could have verbalized to get her away before deciding to kick her because she can let her needs be known, but she just kicked her instead."
Nobody intervened.
Resident 1 told inspectors the kick happened in front of everyone, including facility staff, and that it hurt. She said staff did not respond immediately. Resident 2, interviewed separately the same afternoon, confirmed she kicked toward Resident 1 to get her away. She did not deny it. She described it plainly, without apparent concern that it would be treated as a significant event.
What inspectors found when they looked closer was that the hostility between these two residents had not begun that day and had not ended there.
Resident 2 told inspectors that since the incident, when Resident 1 passed by her room, she would give her the middle finger. Resident 1, for her part, would stop her wheelchair in the hallway outside Resident 2's room and call her "a fucking bitch." The two women, both in wheelchairs, had apparently settled into a sustained pattern of provocation that staff were aware of and had not resolved.
Inspectors did not have to wait long to see it themselves. At 2:46 p.m. on April 30, fourteen minutes after finishing their interview with Resident 2, they observed Resident 1 wheel herself to Resident 2's doorway and stop. Resident 2 yelled, "Keep going!" Resident 1 said, "Oh yea!" and continued down the hallway. A facility staff member was seated approximately ten feet away. The staff member paid no attention.
Registered Nurse 1, interviewed at 3:25 p.m. that same day, acknowledged that Resident 1 had a history of altercations with other residents. RN 1 confirmed it was the facility's responsibility to protect all residents from abuse. The acknowledgment was unqualified. There was no suggestion that the history of altercations had prompted any particular monitoring plan or intervention strategy for either resident.
The Social Service Director was interviewed four days later, on May 4. She defined abuse to inspectors as physical, financial, verbal, neglect, isolation, withholding medications, or withholding visitations. Asked about the incident, she said: "If staff noticed the verbal altercation and yelling, they should had separated the residents immediately." She then said she considered what happened between Resident 1 and Resident 2 to be abuse. "Because one of the residents actually physically touched the other resident and because of the verbal — because they were both cursing at each other."
The Assistant Director of Nursing, also interviewed May 4, reached the same conclusion by the same reasoning. Verbal abuse because the residents were talking vulgarly to each other. Physical abuse because the kick made physical contact. Both definitions, she said, applied.
The facility's own written policies reached the same conclusion before any inspector arrived. Its abuse, neglect, and exploitation policy, dated 2025, listed kicking as an example of physical abuse. It defined verbal abuse as the use of oral, written, or gestured communication that willfully includes disparaging and derogatory terms to residents. It stated that prevention of abuse included identifying, correcting, and intervening in situations in which abuse is more likely to occur, and listed verbal abuse overheard and physical abuse observed as indicators requiring action.
The job description for certified nursing assistants, dated 2020, stated that CNAs protect residents from abuse. The job description for registered nurses, dated 2023, stated the same thing.
What the inspection report describes is a facility where the written policies said the right things, the staff who were interviewed knew the right answers, and the staff who were present in the moment did nothing. CNA 1 did not intervene when Resident 2 kicked Resident 1. The unnamed staff member seated ten feet from the doorway did not intervene when inspectors observed the two residents exchange hostilities on the afternoon of April 30. The gap between what the policy binder said and what happened in the hallway was not a matter of confusion about definitions. Everyone interviewed agreed on what abuse was. Everyone agreed it had occurred. The question the inspection report leaves unanswered is why the knowledge stopped at the interview room door.
Resident 1 told inspectors it upset her. It hurt, she said.
She was in a wheelchair. She was at the nurse's station asking for her nurse. A staff member was ten feet away. She got kicked in the knee, and nobody moved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowood Nursing Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Meadowood Nursing Center in CLEARLAKE, CA was cited for abuse-related violations during a health inspection on April 30, 2026.
That is what inspectors found when they visited Meadowood Nursing Center at 3805 Dexter Lane in late April 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.