The Meadows Health And Rehabilitation Center
The Meadows Health and Rehabilitation Center in Dallas, TX — inspection on November 4, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake, sitting in his wheelchair with nasal cannula on receiving oxygen via concentrator.
During an interview on 11/04/2025 at 2:00 PM, the DON stated that she reviewed and signed the completed MDSs upon completion of all the sections as the RN.
She stated that if the oxygen treatment was not coded, it meant the resident did not use it during the look back period.
She would have to check the resident files.
She did not address the negative outcome to the resident.
During an interview on 11/04/2025 at 2:20 PM, the Administrator stated it was his expectation for the comprehensive MDS assessments to be completed accurately.
During an interview on 11/06/2025 at 1:30 PM with MDS, revealed she completed sections B-health speech and vision, C-Cognitive, D-Mood, E-Behaviors, and Q-participation in Assessments and goal setting.
She stated the importance of the resident's comprehensive MDS being accurate was to ensure the resident received the proper care they needed.
Record review of facility policy dated 03/2022 and titled Resident assessments reflected The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Meadows Health and Rehabilitation Center
8383 Meadow Rd Dallas, TX 75231
SUMMARY STATEMENT OF DEFICIENCIES
Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake sitting in his wheelchair.
Observations revealed an oxygen concentrator water bottle that was not dated.
The resident said the nurse checked the tubing and bottle during rounds. He could not remember when the water bottle change occurred.
During an interview on 11/04/2025 at 1:04 PM with LVN-E stated Resident #1 received oxygen treatments PRN and the tubing was changed during the night shift on Sundays. LVN-E said she changed resident #8's tubing and water bottle 30 minutes after surveyor's observation. LVN-E stated that the overnight staff changes the tubing every Sunday. LVN-E said that the brown colors that were observed on the NC were due to the resident being a heavy smoker, per her Google search today.
During an interview on 11/04/2025 at 2:00 PM, the DON stated the housekeeping staff were responsible for cleaning the oxygen concentrators.
The DON said the oxygen tubing should be changed on Sundays during the night shift and as needed.
The DON said the facility policy did not require the NC to be dated.
The DON said that Resident #1's NC discoloration was due the resident excessively smoking, despite re-education from nursing staff.
The DON said that she was aware of the resident's NC discoloration, however, she was could not say how long it would take for the discoloration to occur on the NC. DON said the tubing should be changed as needed when soiled.
During an interview on 11/04/2025 at 2:18 PM, the ADON stated the staff were responsible for ensuring all the respiratory devices were clean during resident rounds.
She said the staff should change tubing as needed, and she would educate the staff and document in the care plan frequent NC changes for Resident #1.
She stated that another expectation was for the staff to ensure the humidifier bottle was dated when changed.
She said she would coordinate with the DON to do an in-service regarding dating and monitoring respiratory devices and changing the tubing.
During an interview on 11/04/2025 at 2:20 PM, the Administrator stated that Resident #1's tubing was changed on Sundays during the night shift, and it was the ADON and the DON responsibility to monitor clinical treatments.
Record review of the facility policy undated, titled Oxygen Administration reflected PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation: 1.
Verify that there is a physician's order for this procedure.
Review the physician's orders, facility protocol for oxygen administration.2.
Review the resident's care plan to assess any special needs of the resident.3.
Assemble the equipment and supplies as needed.Weekly Documentation 1.
Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.Reporting.1.
Notify the supervisor if the resident refuses the procedure. 2.
Report other information in accordance with facility policy and professional standards of practice.
Facility ID: