Nursing Home News — Page 514

The fall happened on September 28, 2025.

This obligation extends beyond simply responding to incidents after they occur — facilities must proactively anticipate and mitigate risks.

Federal inspectors found the facility violated documentation requirements designed to protect vulnerable nursing home residents during transfers.

But when the resident fell on April 4, 2025, staff had no documentation showing they followed this safety protocol.

The facility has not submitted a plan of correction.

Resident 19 suffers from malignant carcinoid tumor of the small intestine and requires gastrostomy feeding due to severe swallowing difficulties.

To understand the gravity of this finding, it helps to understand how the Centers for Medicare & Medicaid Services (CMS) categorizes nursing home deficiencies.

Federal records showed the facility's last risk-benefit statement for these medications was completed nearly a year ago on September 17, 2024.

"She shared that there was no assessment done," the inspection report states.

The resident, identified in inspection records as R16, has dementia, quadriplegia, and diabetic neuropathy.

Federal inspectors visited the facility on December 23, 2025, responding to a complaint.

The Meadows admitted the resident on November 4 with atrial fibrillation, a heart rhythm disorder.