Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook Post Acute during CMS and state inspections, most recent first.
Surveyors found that two residents were living with a bedroom and shared bathroom that had unpainted primer patches, damaged drywall, peeled and chipped paint, and missing tiles and grout, contrary to facility policy requiring clean, comfortable, safe, and homelike bedrooms. One resident, who was alert, oriented, and wheelchair-bound with a history of CVA, MS, and ataxia, reported that the damaged and unfinished walls and tiles in his room and bathroom were not homelike, while the other alert and oriented resident sharing the bathroom similarly stated that the bathroom did not look good.
A resident with a history of cerebral infarction, multiple sclerosis, and ataxia, who required assistance with mobility and ADLs, did not receive a physician-ordered PT evaluation and treatment. The resident reported never having PT since admission, and both a CNA and an LVN confirmed they had not observed any PT services provided. Record review showed an active order for PT evaluation and treatment, and the administrator acknowledged that this order was not followed, despite a facility policy requiring provision of PT upon written physician order.
Surveyors found that a shared bathroom call light used by two residents in wheelchairs was nonfunctional, providing no visual or audible alert when activated. A CNA, an LVN, the Maintenance Assistant, and the Administrator each confirmed the bathroom call light did not work, despite facility policy requiring a functional call system in toileting and bathing areas. One resident, with MS, stroke history, and ataxia, reported needing assistance in the bathroom and stated he would use the call light if it worked. The other resident, with hereditary neuropathy and kyphosis, also confirmed the shared bathroom call light was not working and noted it would be useful if functional.
Surveyors found the kitchen’s double prep sink area in an unsanitary condition, with both basins covered yet containing dried food particles, a red bucket of yellowish gray fluid under one sink, and a wet blanket on the floor nearby. The DM and ADM reported the sinks had been non-operational for several days due to a collapsed drainage pipe, with unsuccessful in-house repair attempts and plumber evaluations confirming the issue. During this time, staff used plastic bus tubs to clean fruits and vegetables instead of the prep sinks. The Cook confirmed the dirty condition and acknowledged the kitchen was not sanitary, while the DON reported no resident complaints or hospital transfers for food-borne illness, despite a facility policy requiring all kitchen areas to be kept clean and free of garbage and debris.
A resident with dementia and a history of falls experienced multiple unwitnessed falls and injuries due to the facility's failure to implement and document required supervision and monitoring interventions. Despite care plans specifying frequent checks and visual monitoring, staff did not consistently follow or record these measures, and concerns raised by CNAs about the resident's safety were not addressed by nursing leadership.
A large cookie sheet pan was observed with black crusted residue on the edges and corners during a kitchen tour, and the same issue was seen again later when freshly baked cookies were on sheet pans. The cook stated the pans were old and should not have residue, and the DM said food residue had built up over time and could come off into food served to residents.
Care Plan Not Developed for Potassium Chloride Use: A resident with HTN and edema had active orders for potassium chloride ER as a supplement and Lasix for generalized edema, but the record showed no care plan was initiated or developed for the potassium chloride use. The DON and MDS nurse stated the potassium chloride order should have been addressed in the resident’s care plan and reviewed during comprehensive and quarterly assessments, including monitoring effectiveness and side effects.
Failure to follow physician orders for blood glucose management: two residents with diabetes received insulin outside ordered hold parameters, one resident also received glucagon outside the ordered threshold, and staff did not document physician notification for out-of-range blood sugars. The RN and DON confirmed the ordered parameters should have been followed and that the physician should have been notified when blood glucose values were outside the prescribed limits.
Improper Storage of Discontinued and Unidentified Medications: Discontinued meds for two residents were found still stored in medication carts and readily available for use, including clonidine, ibuprofen, ondansetron, and alprazolam. In addition, nine unidentified pills not in their original packaging were found scattered in a medication cart drawer next to resident bubble packs, and the LPN could not identify them. The DON stated the unidentified pills should not have been in the cart.
Remote RD Did Not Perform On-Site Nutritional Assessments: The facility failed to ensure the RD completed comprehensive nutritional assessments on-site. The DM stated the RD worked 100% remotely, reviewed EMR information, and communicated with the DM and DON by phone, with no on-site visits after the prior RD's last visit. The RD stated she was responsible for weight-change monitoring, IDT notification, MDS assessments, and nutrition assessments for new admissions and residents with significant changes, but she was not aware a full assessment needed to be done in person. Residents 54, 55, 56, 57, and 58 were assessed remotely.
A resident on a pureed diet had fruit brought from home, including bananas and green grapes, observed at the bedside and stated he ate the grapes occasionally. Staff interviews showed that food from home should be checked with the LPN/RN before being given, and the RN noted the resident had been downgraded to pureed due to aspiration risk. The facility policy stated foods posing a choking hazard for residents with swallowing difficulty are to be removed and returned to the family or visitor.
Nebulizer Set-Up Not Changed Weekly: A resident with COPD and an order for albuterol via nebulizer had a nebulizer set-up observed with an old date on the label, and it had not been changed after the required weekly interval. The RT, RN, and DON all stated respiratory equipment should be changed every week, and the MAR showed the resident received multiple nebulized treatments while the dated set-up remained in use.
Medication Administration Error Rate Exceeded Threshold: An LVN administered potassium chloride ER and celecoxib without food as ordered for a resident who had eaten breakfast earlier but had no snacks before the morning med pass. The resident’s orders also included ferrous sulfate with food, and the resident had diagnoses of osteoarthritis, abdominal pain, and GERD. The LVN and DON both acknowledged the meds should have been given with food, and the observed errors contributed to a 10.71% medication error rate.
Medications Ordered With Food Were Given Without Food: An LVN administered celecoxib, potassium chloride ER, and ferrous sulfate to a resident without food, despite physician orders to give them with food. The resident had eaten breakfast earlier but had no snacks before the medication pass, and the LVN and DON both confirmed the medications should have been given with food. The resident had diagnoses including osteoarthritis, abdominal pain, and GERD, and the care plan directed staff to give medications as ordered.
Failure to Follow Ordered Therapeutic Diet: A resident with dysphagia and severe cognitive impairment was observed being fed a pureed diet by a CNA even though the physician ordered CCHO with mechanical soft texture and regular consistency. The CNA stated the resident had been given pureed meals on consecutive days, and the meal ticket had "Pureed" written on it despite the ordered diet. The DM said he later changed the ticket, and the DON stated the physician's order should have been followed.
Failure to use required PPE during EBP care was cited when an LVN handled a resident’s feeding tube without wearing a gown, despite EBP signage, PPE being available outside the room, and the resident’s care plan and physician order requiring gowns and gloves for G-tube care. The LVN and DSD both stated a gown should have been worn during the procedure.
The facility did not post complete daily nurse staffing information, as only projected hours were displayed and actual direct care service hours were left blank. The DSD confirmed that actual hours were not calculated or posted daily due to lack of timely access to payroll data, resulting in incomplete staffing information being available to residents and the public.
The facility did not provide or document wound care treatments as ordered by physicians for four residents with complex medical conditions, including diabetes, osteomyelitis, congestive heart failure, and gangrene. On multiple occasions, the Treatment Administration Record lacked evidence that wound care was performed, and staff interviews confirmed the treatments were missed. Facility policy requires documentation of all treatments, but this was not followed for the affected residents.
A resident with multiple chronic conditions was transferred to a hospital for gangrene of the right foot, but the facility did not notify the LTC Ombudsman as required. Review of records and staff interviews confirmed the omission, despite facility policy mandating ombudsman notification for transfers.
Surveyors found a gallon of chocolate syrup with an open date more than six months prior stored on the kitchen counter and available for use. The Dietary Manager and Registered Dietician confirmed that facility guidelines require opened chocolate syrup to be discarded after six months, but this was not done, resulting in expired food being accessible in the kitchen.
Surveyors found the outdoor dumpster overflowing with trash and the lid not fully closed. Both the DM and facility owner confirmed that the dumpster should not be overflowing and the lid should be closed, in accordance with facility policy.
Two residents with respiratory needs did not have their oxygen cannulas and nebulizer masks changed, labeled, or stored according to infection control protocols. Equipment was found undated, left exposed, or not replaced as required by physician orders and facility policy. Staff interviews confirmed that weekly changes and proper storage in plastic bags were not consistently performed.
The facility failed to track and document controlled medications, leading to unaccounted medications for several residents. The DON was informed of missing medication count sheets and cards, and an investigation revealed discrepancies in documentation. The facility lacked a process to monitor receipt and reconciliation of controlled medications, resulting in potential misuse or diversion.
The facility failed to accurately code the MDS for several residents, including those with PASRR Level II evaluations and an indwelling catheter. A resident with severe cognitive impairment and a PASRR Level II was not coded correctly, and another resident with an indwelling catheter was not identified in the MDS. These oversights were acknowledged by the MDS Coordinator and highlighted by the DON and Administrator.
A resident with a urinary catheter was observed without a privacy bag on two occasions, exposing the urine and compromising their dignity. Despite facility policy and staff acknowledgment that privacy bags should be used, the resident's catheter bag remained uncovered. The resident had a history of hemiplegia, hemiparesis, skin infection, and sepsis, and required the catheter for urinary retention and wound management.
The facility failed to create care plans for two residents with urinary catheters, despite their medical histories and hospital interventions. One resident had an indwelling catheter placed for urinary retention, and another had a suprapubic catheter due to a UTI and sepsis. The absence of orders led to the lack of care plans, as care plans were based on MDS triggers. The DON acknowledged the oversight and took responsibility.
The facility failed to obtain orders and create care plans for urinary catheters for two residents upon admission. One resident returned with a suprapubic catheter after a hospital stay, and another was readmitted with an indwelling catheter. Both cases lacked documentation and care plans until identified during a survey. The DON and staff acknowledged the oversight, attributing it to failures in the admission and reassessment processes.
A resident with a history of respiratory issues had an order for supplemental oxygen at 2 lpm, but observations showed the oxygen was set higher than prescribed. The DON confirmed the discrepancy, stating changes should only occur with a new physician's order. The LVN was unaware of the reason for the increased setting, and the Administrator stressed the need to follow all orders.
A facility failed to properly assess and monitor a resident's condition before and after dialysis treatments and did not maintain effective communication with the dialysis center. The resident, with a history of end-stage renal disease, had incomplete Dialysis Assessment Records, missing critical information such as vascular access site assessments and vital signs. Significant incidents, like vomiting and low blood pressure, were not documented, leaving the dialysis center uninformed of these health changes. Staff interviews revealed a lack of communication and protocol adherence, contributing to the deficiency in providing safe dialysis care.
The facility implemented a policy to charge residents $25 if they required staff assistance to outside appointments, potentially deterring necessary medical visits. A resident with multiple diagnoses expressed concern about the charge, and facility leadership confirmed the policy.
Failure to Maintain Homelike Bedroom and Shared Bathroom Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in a resident bedroom and a shared bathroom. During an unannounced complaint investigation, surveyors observed a white patch of dry primer on the wall near the foot of one resident's bed that was not painted to match the rest of the room. In the shared bathroom used by this resident and another resident, surveyors observed peeled paint above the sink, damaged drywall and missing paint around the light switch, missing tiles and grout in the shower area, and a patch of dry, white primer around the toilet that was not painted like the rest of the bathroom. These conditions were confirmed on observation and interview with a CNA, the Maintenance Assistant, and the Administrator, all of whom acknowledged that the bedroom and bathroom did not look like a homelike environment. The resident whose bedroom and bathroom were observed was alert and oriented and was seen in a wheelchair in his room. His medical record showed diagnoses including cerebral infarction (stroke), multiple sclerosis, and ataxia. He stated he did not like the damaged drywall, missing tiles, and unpainted areas in his bathroom and bedroom and that it was not a homelike environment. Another alert and oriented resident, who shared the same bathroom, was observed in a wheelchair outside his room and reported that his bathroom had damaged drywall, missing tiles, chipped paint, and did not look good. The facility’s written policy on bedrooms, dated January 2025, stated that all residents are entitled to clean, comfortable, safe, and homelike bedrooms, which was not met in these observed conditions.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
Surveyors found that the facility failed to provide specialized rehabilitative services as ordered by the physician for one resident. During an unannounced complaint investigation, the resident was observed in a wheelchair, alert and oriented, and reported having multiple sclerosis and not receiving any physical therapy (PT) evaluation or treatment since admission. The resident stated that PT could help with his condition. A certified nursing assistant and a licensed vocational nurse both stated that the resident required assistance with mobility and activities of daily living and that they had not seen the resident receive PT during his stay. Record review showed the resident was admitted with diagnoses including cerebral infarction, multiple sclerosis, and ataxia, and had a physician’s order dated October 30, 2025, for “Physical Therapy evaluation and treatment as indicated.” The administrator confirmed that the resident had not received a PT evaluation or treatment since admission and acknowledged that the physician’s PT order was not followed. The facility’s policy on Specialized Rehabilitative Services, dated December 2009, stated that the facility would provide rehabilitative services, including PT, upon written order of the attending physician, but this policy was not implemented for this resident.
Nonfunctional Bathroom Call Light in Shared Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional bathroom call light system for two residents who shared the same bathroom. During an unannounced complaint investigation on April 7, 2026, surveyors observed that the bathroom call light in the shared bathroom between two rooms did not produce any visual or audible alert when activated. A CNA, an LVN, the Maintenance Assistant, and the Administrator each entered the bathroom, tested the call light, and confirmed it was not working, despite the facility’s written policy stating that the resident call system must remain functional at all times and that residents must have a means to call staff from toileting and bathing areas. Resident 1, who was alert and oriented and used a wheelchair, reported having multiple sclerosis and needing assistance in the bathroom to get in and out of his wheelchair. He stated that the bathroom call light was not working and that he would use it if it were functional. Resident 1’s record showed diagnoses including cerebral infarction, multiple sclerosis, and ataxia. Resident 2, also alert and oriented and using a wheelchair, confirmed that he shared the bathroom and that the bathroom call light was not working, stating it would be nice to have a functioning call light in case he needed to use it. Resident 2’s record reflected diagnoses of hereditary neuropathy and kyphosis. These observations and interviews demonstrated that the facility did not maintain a working call system in the shared bathroom as required by its policy.
Unsanitary Kitchen Prep Sink and Improper Maintenance of Food Preparation Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary conditions and improper maintenance of the kitchen’s double preparation sink. During an initial kitchen tour with the Dietary Manager (DM), both basins of the double prep sink were found covered by a long cookie sheet, with signs posted above each basin stating “DO NOT USE UNDER REPAIR,” yet both sinks contained multiple dried food particles. Under the first prep sink, surveyors observed a red bucket filled with yellowish gray fluid, and a wet yellow blanket was seen on the floor in the corner at the end of the double prep sinks. The DM reported that the prep sinks had a drainage issue beginning on March 18, 2026, that the maintenance supervisor had attempted repairs without success, and that two separate plumbers had determined the drainage pipe under the double prep sink was collapsed beneath the courtyard cement. The DM also stated that kitchen staff were using plastic bus tubs to clean fruits and vegetables during this period. In a concurrent observation and interview with the Administrator (ADM), DM, Cook, and Director of Nursing (DON), the ADM acknowledged that the double prep sinks had been non-operational since March 18, 2026, and confirmed the presence of dirty sinks, the red bucket with yellow-grey water, and the wet yellow blanket on the floor. The Cook stated that the sinks had been non-operational and dirty with old, dried food, with the red bucket of yellow-grey liquid and the wet yellow blanket in place since March 18, 2026, and acknowledged that the kitchen should be sanitary at all times and was not. The DON reported there had been no resident complaints or transfers related to signs or symptoms of food-borne illness. The facility’s written policy on sanitization stated that all kitchens, kitchen areas, and dining areas are to be kept clean and free from garbage and debris, which contrasted with the observed conditions in the prep sink area.
Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident with dementia, anxiety, a history of falls, and impulsive behavior. Despite being identified as high risk for falls and self-harm, the resident experienced eight unwitnessed falls over a period of several months. The care plans for the resident included specific interventions such as being checked and changed every two hours, frequent visual monitoring, and later, checks every 30 minutes. However, there was no documented evidence that these interventions were consistently implemented or monitored by staff. On multiple occasions, the resident was found on the floor or under her roommate's bed, sometimes with visible injuries such as hematomas, skin tears, and severe bruising to the face and hands. Staff interviews revealed that CNAs were aware of the resident's behaviors and risks, but failed to consistently report significant findings, such as swollen eyes, to the nursing staff in a timely manner. Additionally, CNAs reported that their concerns about the resident's safety and the need for increased supervision, such as a one-on-one sitter, were communicated to nursing leadership but not acted upon. Record reviews confirmed the lack of documentation for required monitoring and supervision as outlined in the resident's care plans. The DON acknowledged that the facility did not follow its own policies and procedures for ensuring resident safety and that the falls could have been avoided with proper monitoring. The facility's policy required targeted interventions and adequate supervision to reduce accident risks, but these were not effectively implemented for this resident.
Food-Contact Equipment Had Crusted Residue
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation practices were followed when a large cookie sheet pan was observed with black crusted residue on the edges and corners. During the initial kitchen tour with the Dietary Manager, one large sheet pan was seen with this residue, and on a later observation two large sheet pans with freshly baked cookies were on the metal kitchen table, including one pan with the same black crusted residue on the edges and corners. During interview, the cook stated the large sheet pans were old and said they should not have black crusted residue, adding that the residue could come off when serving food to residents. The Dietary Manager stated some pots and pans were old, that food residue built up over time, and that the crusted black residue could come off and stick in food served to residents. The report also cited FDA Food Code guidance stating food-contact equipment must be cleaned to prevent encrustations and that precleaning helps remove grease and food debris.
Care Plan Not Developed for Potassium Chloride Use
Penalty
Summary
The facility failed to ensure a care plan was developed and/or initiated to address the long-term use of potassium chloride ER for Resident 33. Resident 33 was admitted with diagnoses including hypertension and localized edema, and the active physician orders included potassium chloride ER 40 mEq by mouth daily for potassium supplement, ordered on June 22, 2021, and Lasix 40 mg by mouth daily for generalized edema, ordered on August 18, 2025. The care plan report dated June 19, 2024, addressed Lasix and noted the resident was at risk for adverse effects, with interventions to monitor for potential risk/effects and alert the MD when indicated. Record review found no documented evidence of a care plan initiated and/or developed for potassium chloride ER since it was ordered. During interview, the DON stated Resident 33 did not have an active care plan for potassium chloride supplement and that a care plan should have been initiated and/or developed when the medication was ordered in June 2021 to include monitoring the effectiveness and/or side effects. The MDS Nurse stated she was responsible for reviewing and updating care plans during comprehensive and quarterly assessments, that the potassium chloride order was probably an adjunct to Lasix use, and that the indication for potassium chloride should have been reviewed and clarified with the physician during comprehensive and quarterly assessments, but this was not done.
Failure to Follow Blood Glucose Medication Orders
Penalty
Summary
The facility failed to follow physician orders for blood glucose management for two residents with diabetes. Resident 7 had diagnoses including diabetes mellitus, long-term insulin use, and dementia, and the physician had documented that the resident had no capacity to make decisions. The physician ordered insulin lispro 6 units after meals with instructions to hold the dose if blood sugar was less than 150. The MAR showed multiple administrations of insulin lispro when the resident’s blood sugar was below that ordered parameter, including readings of 131, 144, 126, 143, 140, 147, and 117. During interview, an LVN stated these doses should not have been given because they were outside the ordered hold parameter. Resident 7 also had a physician order for glucagon emergency injection kit 1 mg to be given as needed for blood sugar less than 60. The MAR showed glucagon was administered when the resident’s blood sugar was 97, which was outside the ordered parameter. The record also showed a blood sugar of 62 on September 16, 2025, and there was no documented evidence that the physician was notified. Staff interviews confirmed the facility expectation was to notify the physician when blood sugar was outside ordered parameters, and the DON stated Resident 7 should not have received insulin or glucagon outside those parameters. Resident 38 had diabetes mellitus, no capacity to make decisions per the history and physical, and a BIMS score of 7 indicating severe impairment. The physician ordered insulin aspart 5 units subcutaneously once daily and to hold if blood sugar was below 200. The MAR showed the insulin was administered on multiple occasions when blood sugar was below 200, including readings of 147, 105, 188, 150, 198, 190, 125, 133, and 128. The RN stated the insulin should have been held for blood sugar below 200 and that the resident could have experienced hypoglycemia. The RN also stated there was no documentation that the physician was notified when blood sugar was below the ordered parameter, and the DON stated the licensed nurse should have notified the physician so the order could be adjusted.
Improper Storage of Discontinued and Unidentified Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in two medication carts. In Medication Cart 1, discontinued medications for Resident 5 and Resident 35 were still stored and readily available for use, including clonidine 0.2 mg, ibuprofen 400 mg, and ondansetron, even though the LVN stated each medication had been discontinued months earlier. In Medication Cart 2, discontinued alprazolam for Resident 7 was also found stored in the cart, and the LVN stated it should have been removed and turned in to the DON for destruction. The facility policy stated discontinued medications are to be destroyed or returned to the dispensing pharmacy, and the nurse receiving the discontinuation order is responsible for documenting it and notifying the pharmacy. During inspection of Medication Cart 1, nine unidentified pills were also found scattered in the medication cart drawer next to residents’ bubble pack medications. The pills were variable in color and size and were not in their original container or packaging, and the LVN could not identify them. The LVN stated they should have been destroyed and not stored in the medication cart. The DON later stated the unidentified pills should not have been in the cart and were not safe. The facility policy stated medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and discontinued, outdated, or deteriorated medications are to be handled through the dispensing pharmacy.
Remote RD Did Not Perform On-Site Nutritional Assessments
Penalty
Summary
The facility failed to ensure the Registered Dietician (RD) conducted comprehensive nutritional assessments on-site from August 12, 2025, to September 25, 2025. During an interview with the Dietary Manager, he stated the RD worked 100% remotely, obtained resident information from the electronic medical record, and communicated with him and the DON by telephone. He also stated the RD did not perform any on-site visits, and that the previous RD's last on-site visit was on August 11, 2025. During a telephone interview, the RD stated she also worked 100% remotely and had started helping in July 2025 after the previous RD's last day on August 11, 2025. She stated she was responsible for identifying significant weight changes, notifying the IDT, conducting MDS assessments, and completing nutrition assessments for newly admitted residents and residents with significant changes. The RD stated she was not aware she needed to perform a full assessment in person and that she reviewed residents' electronic records and collaborated with the nurses, DON, and DM by telephone and email. The Administrator stated the facility had an RD who came to the facility on a regular basis but quit, and that the remote RD communicated with the DM and DON via email or telephone. Residents 54, 55, 56, 57, and 58 were assessed remotely by the RD.
Food From Home Not Checked Against Pureed Diet Order
Penalty
Summary
The facility failed to ensure that food brought from home was consistent with Resident 10’s ordered pureed diet. During a meal observation, Resident 10 was seen in bed with a meal tray containing a pureed diet, while a banana and green grapes in a plastic container were also on the bedside table. In interview, Resident 10 stated the fruit had been brought in by family and that he ate the grapes occasionally; he also stated he was not sure why he was given baby food. Record review showed Resident 10 was admitted with diagnoses including anxiety disorder and diabetes, and his history and physical described him as alert, cooperative, and without signs of cognitive impairment. The physician’s order specified a regular diet with pureed texture, and the RN stated the resident had been downgraded from mechanical soft to pureed due to aspiration risk. Staff interviews indicated that food brought from home should be checked with the licensed nurse before being given to a resident, and the facility policy stated foods presenting a potential choking hazard for residents with swallowing difficulty are to be taken from the resident and returned to the family or visitor.
Nebulizer Set-Up Not Changed Weekly
Penalty
Summary
The facility failed to ensure a nebulizer set-up used for respiratory treatment was changed after seven days for one resident who had COPD and an order for albuterol sulfate 2.5 mg via nebulizer every 4 hours as needed for shortness of breath or cough. During observations on September 22 and September 24, 2025, the resident was in bed, awake and alert, and a nebulizer set-up was seen in a clear plastic bag hanging on the wall labeled with the resident’s name, room number, and a date of 8/25. The Respiratory Therapist verified the date on the nebulizer set-up and stated respiratory equipment, including nebulizer set-ups, should be changed every week. During interviews, the RT stated licensed nurses gave the resident’s nebulized treatments and should check the date of the nebulizer set-up before administering treatment, and that the licensed nurse should have changed the nebulizer set-up once a week. An RN stated respiratory set-up should be changed once a week and that the licensed nurse administering the treatment should check the date before use. The DON stated the RT was responsible for changing respiratory set-up, but the licensed nurse could also change it and should have changed the nebulizer set-up according to facility policy and procedure. The resident’s MAR showed nebulized treatments were given multiple times in September 2025, and the facility policy stated equipment and tubing should be changed every seven days or according to facility protocol.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent when 3 medication errors were observed out of 28 opportunities during a medication pass for one resident. During observation on September 24, 2025, an LVN prepared and administered multiple medications to the resident, including potassium chloride ER, celecoxib, and ferrous sulfate, which were ordered to be given with food. The LVN administered potassium chloride ER and celecoxib without food, and the resident stated her last meal was at 7:00 a.m. and she had not had any snacks before receiving the morning medications at 9:04 a.m. Record review showed the resident had diagnoses including osteoarthritis, generalized abdominal pain, and GERD. The active physician orders directed potassium chloride ER 40 mEq by mouth with food daily, celecoxib 200 mg by mouth with food twice daily, and ferrous sulfate 325 mg by mouth with food twice daily. During interview, the LVN stated she did not administer these medications with food as ordered and acknowledged the resident may experience GI upset if they were taken without food. The DON also stated the medications should have been given with food and that the resident was at high risk for stomach upset because of chronic abdominal pain and GERD.
Medications Ordered With Food Were Given Without Food
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error when celecoxib, potassium chloride ER, and ferrous sulfate were administered without food as ordered by the physician. During a medication pass observation, the LVN prepared these medications for the resident, all of which had instructions to give with food, and then administered them without food. The resident stated her last meal was at 7:00 a.m. and she had no snacks before taking the medications at 9:04 a.m. A concurrent interview and record review confirmed the physician orders for potassium chloride ER 40 mEq daily with food, celecoxib 200 mg twice daily with food, and ferrous sulfate 325 mg twice daily with food. The resident’s record showed diagnoses including osteoarthritis, generalized abdominal pain, and GERD, and care plans identified risks for GI distress or bleeding, anemia, and chronic pain with directions to give medications as ordered. The LVN acknowledged the medications were not given with food and stated the resident may experience GI upset. The DON also confirmed the medications should have been administered with food and noted the resident was at high risk for stomach upset because of chronic abdominal pain and GERD.
Failure to Follow Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received the diet ordered by the physician. During a meal observation on September 22, 2025, Resident 5 was seen in the dining room being fed by CNA 2 while lying in a Geri chair. CNA 2 stated she was feeding the resident a pureed diet, and the resident's laminated meal ticket was verified with her. Although the ticket listed CCHO, regular consistency, it also had "Pureed" written on it in black marker. Record review showed Resident 5 was admitted with dysphagia and had a BIMS score of 3, indicating severe impairment. The physician order dated July 2, 2025, directed a CCHO diet with mechanical soft texture and regular consistency, and the care plan also identified a CCHO, mechanical soft diet with instructions to provide and serve the diet as ordered. CNA 2 stated she fed Resident 5 pureed meals on two consecutive days and said the meal ticket had "Pureed" written on it during those days. The Dietary Manager stated he changed the laminated meal ticket on September 23, 2025, after being informed it had a smear from a black marker, and said he was not aware the resident had been receiving a pureed diet. The DON stated the physician's order should have been followed and that nurses should check the resident's diet order list before trays were passed.
Failure to Use Required PPE During EBP Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after a staff member was observed not following infection control measures for a resident on Enhanced Barrier Precautions (EBP). On September 25, 2025, at 9:04 a.m., an LVN entered Resident 3’s room and handled the resident’s feeding tube without wearing the recommended PPE, specifically a gown. An isolation cart with PPE, including gowns, was observed outside the room, and a posted sign indicated the resident was on EBP. In a concurrent interview, the LVN stated Resident 3 was on EBP precautions and that she should have worn a protective gown when disconnecting the feeding tube. The DSD later stated the LVN should have worn appropriate PPE when handling the feeding tube because the gown was needed to prevent cross-contamination due to exposure to bodily fluids. Resident 3’s record showed diagnoses including dysphagia, gastrostomy, and dementia, and the physician’s order and care plan identified EBP related to the G-tube, with gowns and gloves required during care. The facility policy stated EBP applies to residents with indwelling medical devices, including feeding tubes, and uses targeted gown and glove use.
Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data was complete and accurate, as required. During an unannounced visit, it was observed that the posted documents for nurse staffing, specifically the Census and Direct Care Services Hours Per Patient Day (DHPPD), only included projected (estimated) hours and did not have the actual direct care service hours, average patient census, actual DHPPD, or actual CNA hours filled in for the reviewed dates. The section of the form designated for actual hours was left blank, despite instructions that it must be completed at the end of each 24-hour patient day. Interviews with the Director of Staff Development (DSD) revealed that actual DHPPD hours were not calculated or posted daily because the DSD did not have access to payroll hours until the day after paydays, which occur twice a month. As a result, only projected staffing hours were posted, and actual staffing data was not made available to residents and the public on a daily basis as required. This omission was verified during both document review and staff interviews.
Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide wound care treatments in accordance with physician orders for four residents. For one resident with diagnoses including diabetes, hypertension, osteomyelitis, and chronic kidney disease, the Treatment Administration Record (TAR) showed that wound care for a right foot stump was not documented as provided on three specific dates, despite active orders for daily or every-other-day treatment. Another resident with low back pain, congestive heart failure, and hypertension had no documentation of ordered wound care for a left heel wound on three separate dates, as indicated by the TAR. A third resident, diagnosed with diabetes, chronic obstructive pulmonary disease, and dysphagia, had no documentation of wound care for a left great toe on two dates, despite an order for daily treatment. The fourth resident, with subdural hemorrhage, gangrene, and on palliative care, had no documentation of wound care for a gangrenous toe on one date, even though the order specified treatment every 48 hours. In each case, the TAR lacked evidence that the prescribed wound care was performed as ordered. Interviews with the Treatment Nurse and the Director of Nursing confirmed that the wound treatments were not documented or administered on the specified dates for all four residents. The facility's policy requires that all treatments and procedures be documented in the resident's medical record, including details such as date, time, procedure, assessment, and the signature of the individual providing care. The absence of documentation and confirmation from staff indicated that the required wound care treatments were not provided as ordered.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman when a resident was transferred to a general acute care hospital. The resident, who had a medical history including diabetes, hypertension, osteomyelitis of the right foot, and chronic kidney disease, was transferred to the hospital for gangrene of the right foot. Documentation reviewed included the resident's admission record, progress notes, and SBAR, all confirming the transfer and the medical reasons for it. However, there was no evidence in the records that the ombudsman was notified of this transfer. Interviews with the Social Worker, Director of Nursing (DON), and Administrator confirmed that the facility's process requires notification of the ombudsman for all transfers or discharges, and that this notification did not occur in this case. The facility's policy also specifies that notice should be given to the ombudsman as soon as practicable before a transfer. Both the Social Worker and DON acknowledged the omission, and the Administrator verified the lack of documentation regarding ombudsman notification for the resident's transfer.
Expired Chocolate Syrup Found in Kitchen Storage
Penalty
Summary
During a kitchen tour, surveyors observed a gallon of chocolate syrup with an open date of October 19, 2023, stored on top of the kitchen overhead counter and readily available for use. The Dietary Manager confirmed that the chocolate syrup should have been discarded six months after opening, according to the facility's dry goods storage guidelines, but it remained accessible to staff well past this period. The Registered Dietician also stated that no expired food or food stored beyond its shelf life should be present in the kitchen, whether opened or not. The facility's documented guidelines specify that opened chocolate syrup should be discarded after six months, but this was not followed, resulting in the presence of expired food in the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an inspection of the facility's garbage disposal area, surveyors observed that the outdoor trash dumpster located by the parking lot was overflowing with trash and its lid was not completely closed. The Dietary Manager confirmed during the inspection that the dumpster should not be overflowing and that the lid should be fully closed to prevent attracting pests. The facility owner also acknowledged in an interview that the dumpster should not be overflowing and the lid should be closed. A review of the facility's policy on food-related garbage and refuse disposal indicated that outside dumpsters are to be kept closed and free of surrounding litter.
Failure to Follow Infection Control Practices for Respiratory Equipment
Penalty
Summary
The facility failed to follow infection control practices for two residents who required respiratory equipment. For one resident with a history of pneumonia, the oxygen cannula in use was not dated, and a nebulizer mask was found undated and left exposed on the nightstand, rather than being stored in a plastic bag as required. The resident's physician order specified that the nasal cannula and mask should be changed weekly, and facility policy required respiratory equipment to be labeled, dated, and stored in a plastic bag when not in use. Staff interviews confirmed that these procedures were not followed, and the equipment was not properly stored or dated. For another resident, also with a diagnosis of pneumonia, the nebulizer mask had not been changed since admission, despite physician orders and facility policy requiring weekly changes. The mask was observed in a belongings bag with an outdated label, and the resident confirmed that the mask had not been replaced since admission. Staff interviews revealed that the responsibility for changing the equipment was assigned to the night shift, but the change had not occurred as scheduled. The equipment was also not stored according to infection control protocols. Both residents' records and staff interviews indicated a lack of adherence to established infection control policies regarding the maintenance, labeling, and storage of respiratory equipment. The facility's own procedures required weekly changes and proper storage of such equipment to prevent contamination, but these steps were not consistently implemented for the residents reviewed.
Failure to Track and Document Controlled Medications
Penalty
Summary
The facility failed to implement a system to accurately track the movement of controlled medications, leading to the inability to account for missing controlled medications for ten residents. The Director of Nursing (DON) was informed by a Licensed Vocational Nurse (LVN) about missing controlled medication count sheets and medication cards for two residents. An investigation revealed that a total of ten residents were affected by the missing controlled medications. The facility suspected a new hire per diem nurse of diverting the medications, and a police report was filed. However, the facility lacked a process to monitor the receipt of controlled medications, and the DON admitted there was no reconciliation process in place to identify loss or potential diversion. Additionally, during a random controlled medication audit, discrepancies were found in the documentation of medication administration for four residents. The controlled medications were signed out on the count sheet but not documented on the Medication Administration Records (MAR), resulting in inaccurate accountability. For instance, Resident 11 had two doses of Norco unaccounted for, and Resident 12 had eight doses missing. Similar discrepancies were found for Residents 9 and 13 with their Ativan prescriptions. The nursing staff failed to document the administration of these medications on the MAR, as required by the facility's policy and procedure. The facility's policies on controlled substances and medication administration were not followed, contributing to the deficiencies. The policies required that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, and that medication administration be documented immediately on the MAR. The failure to adhere to these policies resulted in unaccounted controlled medications, raising concerns about potential misuse or diversion.
Inaccurate MDS Coding for Residents with PASRR Level II and Indwelling Catheters
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for several residents, leading to deficiencies in the assessment and care planning process. Resident #11, who was admitted with a history of major depressive disorder, schizophrenia, bipolar disorder, and anxiety disorder, had a Preadmission Screening and Resident Review (PASRR) Level II evaluation completed, which was not accurately reflected in the MDS. The MDS Coordinator acknowledged forgetting to code the PASRR Level II, despite the information being available in the resident's electronic health record. Similarly, Resident #18, with a history of major depressive disorder and schizophrenia, also had a PASRR Level II evaluation that was not coded in the MDS. The resident's care plan indicated the use of psychotropic medications for schizophrenia, yet the MDS did not reflect the PASRR Level II status. The Director of Nursing and the Administrator both expressed expectations for accurate MDS coding, but the oversight persisted. Additionally, Resident #39, who had severe cognitive impairment and a PASRR Level II evaluation, was not accurately coded in the MDS. The MDS Coordinator admitted that the PASRR Level II should have been triggered. Furthermore, Resident #26, who had an indwelling urinary catheter, was not coded for the catheter in the MDS, as the MDS Coordinator did not notice the catheter and there were no orders prompting its inclusion. These inaccuracies in MDS coding highlight a pattern of oversight in the facility's assessment process.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to ensure the use of a privacy bag for a resident with a urinary catheter, compromising the resident's right to a dignified existence. The resident, who was admitted with a medical history of hemiplegia, hemiparesis following a stroke, skin infection, and sepsis, had an indwelling urinary catheter due to urinary retention and wound management. Observations on two separate occasions revealed that the resident's urinary catheter bag was not covered with a privacy bag, exposing the urine. Interviews with facility staff, including CNAs, an LVN, the Director of Nursing, and the Administrator, confirmed that urinary catheter bags should be covered with privacy bags. Despite this policy, the resident's catheter bag was observed without a privacy cover, indicating a lapse in adherence to the facility's policy and the resident's rights. The Director of Nursing acknowledged the requirement for privacy bags and expressed uncertainty about why it was not being used for the resident.
Failure to Develop Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with urinary catheters, as required by their policy. Resident #26 was admitted with a history of hemiplegia, hemiparesis, and sepsis, and had an indwelling urinary catheter placed during a hospital stay for urinary retention. Upon readmission to the facility, there were no orders or care plans related to the urinary catheter, and the MDS Coordinator did not notice the catheter during the assessment, leading to the absence of a care plan. The Director of Nursing (DON) acknowledged that a care plan should have been created for the urinary catheter. Resident #34, with a history of obstructive and reflux uropathy and hydronephrosis, was admitted to the hospital where a urinary catheter was placed due to a UTI and sepsis. Upon returning to the facility, there were no orders or care plans for the suprapubic catheter. The MDS Coordinator stated that care plans were created based on MDS triggers, and since there was no order for the catheter, it was not included in the care plan. The DON admitted that the staff missed the catheter during readmission and took responsibility for the oversight. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans were typically created based on MDS triggers and that nurses had the ability to update them. However, the absence of orders for the urinary catheters led to the lack of care plans for both residents. The Administrator and DON both expressed that care plans should be completed timely and accurately, covering all necessary aspects of resident care.
Failure to Document and Manage Urinary Catheters for Two Residents
Penalty
Summary
The facility failed to ensure that upon admission, orders were obtained for the placement and ongoing care and maintenance of urinary catheters for two residents. Resident #34 was admitted with a suprapubic catheter following a hospital stay for sepsis secondary to pyelonephritis and a right-sided staghorn ureteral calculus. Despite returning to the facility with the catheter, there were no orders or care plans in place for its management until a recertification survey identified the oversight. The Director of Nursing (DON) acknowledged the lapse, stating that the staff missed the catheter during the resident's readmission assessment. Similarly, Resident #26 was readmitted to the facility with an indwelling urinary catheter placed during a hospital stay for urinary retention. The facility's records did not reflect any orders or care plans for the catheter until the deficiency was noted during a recertification survey. The MDS Coordinator and Licensed Vocational Nurse (LVN) #2 both confirmed that the catheter was not documented in the resident's chart, and the DON admitted that the catheter should have been noted during the admission assessment. Interviews with facility staff, including the Administrator, revealed that the admitting nurse should have conducted a full body assessment and contacted the doctor for orders regarding the urinary catheters. The lack of documentation and care planning for the catheters was attributed to failures in the admission and reassessment processes, as well as a lack of communication among the nursing staff.
Failure to Follow Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident requiring supplemental oxygen. Resident #17, who was admitted with a medical history of shortness of breath, acute upper respiratory infection, and dependence on supplemental oxygen, had an active order for oxygen therapy at 2 liters per minute (lpm) due to continuously low oxygen saturation. However, observations on two separate occasions revealed that the resident's oxygen was set at higher levels than prescribed, specifically at 4 lpm and 5 lpm. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the oxygen settings were not in accordance with the physician's order. The DON acknowledged that the oxygen should have been maintained at 2 lpm and that any changes to the oxygen settings should have been preceded by obtaining a new order from the doctor. The LVN was unaware of why the oxygen setting was increased, and the facility's Administrator emphasized the importance of following all orders and obtaining a new order if the resident's oxygen saturation levels were low.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's condition before and after dialysis treatments, as well as maintain effective communication with the dialysis center. The facility's policy required licensed nurses to complete baseline information and pre- and post-dialysis sections of the Nurses Dialysis Communication Record, but these were often incomplete. For Resident #53, who had a history of end-stage renal disease and was dependent on dialysis, several Dialysis Assessment Records lacked critical information such as vascular access site assessments, pre-dialysis weight, and vital signs. The facility also failed to document significant incidents related to the resident's condition. For instance, after returning from dialysis, the resident experienced vomiting, and there was no documentation of this episode in the Dialysis Assessment Record. Additionally, the resident had multiple instances of low blood pressure following dialysis, which were not recorded in the assessment records. These omissions meant that the dialysis center was not informed of the resident's low blood pressure or the new medication order for Midodrine to manage this condition. Interviews with facility staff revealed a lack of communication and protocol adherence. A dialysis technician noted that the facility did not communicate important information, such as low blood pressure readings and medication changes, which could have influenced the dialysis treatment approach. The Director of Nursing and other staff acknowledged that the dialysis center should have been informed of the resident's nausea, vomiting, and low blood pressure to ensure appropriate care. The facility's failure to document and communicate these critical health changes contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Facility Imposed Charges for Staff Assistance to Outside Appointments
Penalty
Summary
The facility failed to ensure residents were free of imposed charges for services required to achieve their goals and needs safely. Specifically, the facility developed and implemented a policy to charge residents $25 if they required facility staff to accompany them to appointments outside of the facility. This policy was communicated to residents starting February 1, 2024, and had the potential to deter residents from attending necessary appointments due to the additional cost. Resident 1, who has multiple diagnoses including osteoarthritis of the hip, spondylosis, mood disorder, and anxiety, expressed concern about the charge and indicated she might avoid outside appointments because of it. During the investigation, it was confirmed that Resident 1 needed substantial assistance with transfers and used a wheelchair for mobility. The facility's Director of Nursing and Administrator both confirmed the implementation of the $25 charge for staff assistance during outside appointments. The facility's policy and notice letter regarding the escort service fee were reviewed, both indicating the new charge. This policy potentially imposed charges on residents for services that should be covered, thereby violating residents' rights and potentially impacting their access to necessary medical care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 263 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hemet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ramona Rehabilitation And Post Acute Care Center | 0.6 mi | ★★★★★ | 15 | 1 |
| Hemet Hills Post Acute | 1.2 mi | ★★★★★ | 7 | 0 |
| San Jacinto Valley Post Acute | 1.4 mi | ★★★★★ | 14 | 0 |
| Devonshire Care Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Hemet Valley Healthcare Center | 1.5 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Meadowbrook Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.