Provider Name: MEADOW LAKE HEALTH CENTER
Address: 16044 COUNTY ROAD 165, TYLER, TX 75703
Phone: (903) 526-5599
County: Smith (892)
Ownership Type: Non profit - Corporation
Certified Beds: 30
Average Residents Per Day: 26.0 ()
Provider Type: Medicare, Resides in Hospital: No
Legal Business Name: MEADOW LAKE, LLC
First Approved Date: May 31, 2011
Affiliated Entity: ()
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Both
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 4 ()
QM Rating: 4 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.79008, LPN Staff Hours Per Day: 0.6947, RN Staff Hours Per Day: 0.6288, Licensed Staff Hours Per Day: 1.3236
Total Nurse Staff Hours Per Day, per resident: 4.11375
Weekend Nurse Staff Hours: 3.78570, Weekend RN Staff Hours: 0.4178
PT Staff Hours Per Day, per resident: 0.0695
Nurse Staff Turnover: 66.7, Nurse Turnover Note:
RN Turnover: 40.0, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2157, Case Mix LPN Hours Per Day: 0.7563, Case Mix RN Hours Per Day: 0.3506
Adjusted Nurse Aide Hours Per Day, per resident: 2.56537, Adjusted LPN Hours Per Day: 0.6779, Adjusted RN Hours Per Day: 0.6757
Total Adjusted Nurse Hours Per Day, per resident: 3.90245
Adjusted Weekend Nurse Hours Per Day, per resident: 3.59125
Health Survey Dates and Scores: Cycle 1: 2023-07-19 (Score: 16), Cycle 2: 2022-06-15 (Score: 12), Cycle 3: 2021-05-12 (Score: 32)
Total Weighted Health Score: 17.333
Reported Incidents: 0, Substantiated Complaints: 1
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 15986.70, Payment Denials Number: 0, Total Penalties Number: 4
Location and GPS: 16044 COUNTY ROAD 165,TYLER,TX,75703 (32.2788, -95.304)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-20
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-20
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-11
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0711, Version: New
Description: Provide a written emergency evacuation plan.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-29