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
Staffing
Hours and turnover
RN hours / resident day
1.19
Registered nurse staffing
LPN hours / resident day
0.39
Licensed practical nurse staffing
Aide hours / resident day
2.53
Nurse aide staffing
Weekend hours
3.43
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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