Cycle 1
Health 2025-09-24 · Fire 2025-09-24
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tyler, TX
Meadow Lake Health Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies
16044 County Road 165, Tyler, TX
(903) 526-5599
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
2011-05-31
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,323
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.3
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.44% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.97
Baseline 5.83% · Performance 6.05% · Measure score 5.97 · Achievement 5.97 · Improvement 0
Total nurse turnover
2.63
Baseline 60.53% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 1.63
Adjusted total nurse staffing
4.73
Baseline 4.81 hours · Performance 4.42 hours · Measure score 4.73 · Achievement 4.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 7.77% · Lower 95% interval 6.96% |
| Discharge to community | 55.37% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 53.85% · Lower 95% interval 48.18% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.53% |
95.27%
3.3 pts better
|
Numerator 67 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 24 · Denominator 42 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 20 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 68 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 2.86% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 75% |
42%
33 pts better
|
Numerator 78 · Denominator 104 |
| Discharge function score | 59.52% |
56.45%
3.1 pts better
|
Numerator 25 · Denominator 42 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 2.94% |
25.2%
22.3 pts worse
|
Numerator 1 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
97.9%
2.4 pts worse
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
2.7%
3.4 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
3.3%
2.8 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 61.1% |
18.9%
42.2 pts worse
|
19.6%
41.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 61.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
10.8%
0.3 pts worse
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
16.1%
7.5 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
15.0%
4.3 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.2%
1.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 3.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.0%
About the same
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 13.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
25.9%
0.1 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 27.5% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-19 · Fire 2023-07-19
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-20
D · Potential for more than minimal harm
2024-08-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-22
E · Potential for more than minimal harm
2023-07-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-20
Penalties and ownership
What sits behind the stars
Ownership
Bell, Robbin
W-2 Managing Employee · Individual
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Director · Individual
Jantzen, Jesse
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Pope, Erin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Providence Park Rehabilitation and Skilled Nursing
Tyler, TX
3-star overall rating with 2-star inspections with $265,674 in total fines with 3 recent health deficiencies
#2
Reunion Plaza Healthcare & Rehabilitation
Tyler, TX
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The Heights Of Tyler
Tyler, TX
3-star overall rating with 3-star inspections with $39,574 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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