Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowood A Health And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and kitchen equipment were found out of compliance when surveyors observed a box of carrots in the freezer without an open date, an expired tote of thickener powder, four scratched and worn non-stick fry pans, and a blender stirring rod with deep gouges and a missing piece of plastic. The CDM confirmed the labeling and expiration issues, stated the thickener should have been discarded, and acknowledged the damaged pans and blender part should have been replaced; staff were also using metal spatulas with the non-stick pans instead of the designated plastic utensils.
Infection control practices were not followed during resident care and medication preparation. A resident on contact isolation for C. diff was entered without gown and gloves, an LPN did not perform hand hygiene after a BP check before preparing meds for a resident, the LPN handled an aspirin tablet with bare hands during med prep for another resident, and two pill cutters were found with visible pill residue on medication carts.
Incomplete CGM Orders and Lack of Staff Competency for Blood Glucose Monitoring: A resident with DM and insulin orders had a CGM in place, but nursing staff used CGM readings for blood glucose monitoring and insulin administration without a complete physician order authorizing that practice. The record showed no facility protocol for verifying CGM accuracy with finger-stick testing, and staff interviews confirmed there was no documented in-service or competency validation for CGM use and management, while the DON stated the facility lacked a specific CGM policy.
A resident with a high Braden score and multiple skin impairments, including a Stage 3 PI and an unstageable PI, was observed on a LAL mattress that was set at 180 pounds even though the resident’s documented weight was 106.5 pounds. Staff confirmed the setting did not match the resident’s current weight, and the record showed there were no specific orders or eMAR tasks for routine nursing checks of the mattress setting or function.
A resident with acute respiratory failure with hypoxia, COPD, pneumonia, and OSA used CPAP at bedtime, but the physician order only said CPAP at bedtime and did not include the prescribed pressure settings or other key parameters. During observation, the CPAP machine, tubing, and humidifier were present at the bedside, and the resident stated she did not know about the setup. An LPN confirmed the order was incomplete, and the DON stated the order needed to be complete and specific for safe respiratory care.
Medication Supply Management Failure: Two residents missed ordered medications because supplies were unavailable during med pass. One resident did not receive a Lidocaine patch and later reported right hip pain, while another resident on dialysis missed two doses of Calcium Acetate because it had to be reordered. An LN noted the missing medications, and the DON stated nurses are expected to track supply and reorder timely so treatments are not delayed.
Opened sterile packing strips were found in a treatment cart without dates or times, an opened 100 mL NS bottle was being reused for multiple residents despite the label stating DO NOT REUSE, and the vault used for narcotics awaiting destruction was not permanently affixed. Staff and the DON acknowledged the storage and labeling practices did not match facility policy or the manufacturer’s instructions.
A resident with dementia, impaired mobility, and legal blindness was found with tape placed over the reset button on the call light panel in the room, making the call light nonfunctional. A Maintenance Lead observed the resident repeatedly pressing the call light and reported that the resident could not see the panel issue because of blindness. The assigned CNA denied placing the tape, but staff interviews and the DON’s statements identified the taped call light as neglect because it prevented the resident from calling for help.
A resident with impaired mobility was unable to summon assistance due to a malfunctioning call light that did not illuminate outside the room, resulting in an episode of incontinence when staff did not respond. Staff were unaware of alternative communication methods, and the resident was not provided with a hand bell, despite facility policy requiring such measures during call light outages.
The facility failed to record the temperature of soup served to eight residents during lunch, risking foodborne illness. Dietary staff heated soup without documenting its temperature, contrary to facility policies requiring temperature checks to ensure food safety.
The facility failed to implement proper infection control measures for residents on Enhanced Barrier Precautions (EBP). Signage indicating the need for PPE was missing from a resident's room, and PPE supplies were not readily available outside the rooms of several residents on EBP, increasing the risk of infection spread. Staff confirmed the absence of necessary precautions, and the facility's policy for isolation precautions was not followed.
A resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed, compromising her dignity. The resident required assistance with feeding, but staff fed another resident instead. When finally fed, the meal was at an inappropriate temperature. Staff interviews and facility policies confirmed the failure to promptly assist and serve food at the correct temperature.
A facility failed to maintain a resident's Advance Directive in their medical record, despite the POLST form indicating its existence. The resident, admitted with hip surgery aftercare and a femur fracture, did not have their Advance Directive in either their physical chart or EHR. Interviews with the SSD and DON confirmed this oversight, which contradicted facility policy requiring the document's inclusion and review during admission and quarterly.
A resident's privacy was compromised when their incontinence care instructions were publicly displayed in their room. The instructions, related to the use of a condom catheter, were posted on the bathroom door facing into the room, visible to anyone entering. Staff acknowledged the breach and noted that the information could have been placed inside the bathroom door to maintain privacy.
A resident with Parkinsonism and dementia was unable to independently unbuckle a self-release belt in their wheelchair, classifying it as a restraint. Despite initial approval and demonstration of the belt's use, the resident was observed struggling to release it, requiring assistance from a nurse. The facility failed to reassess the resident's ability to use the belt independently during the quarterly MDS assessment, leading to a deficiency.
A resident in the facility was found to be receiving an incorrect oxygen rate due to the absence of a care plan for their oxygen needs. The resident was supposed to receive oxygen at 4 LPM continuously, but was instead receiving 2.5 LPM. Both the LN and DON confirmed the lack of a care plan, which is crucial for guiding nursing staff in administering the correct oxygen rate.
A resident with multiple diagnoses, including sepsis and bilateral hydronephrosis, experienced inadequate urinary catheter care when their catheter bag was found on the floor without a dignity cover. This was confirmed by two LNs and the DON, who acknowledged the risk of contamination and the importance of maintaining resident dignity. Facility policy and CDC guidelines were not followed, potentially affecting the resident's self-worth and increasing the risk of infection.
A resident receiving oxygen therapy was administered 2.5 LPM instead of the prescribed 4 LPM, as confirmed by a licensed nurse and the DON. This failure to follow the physician's order placed the resident at risk for hypoxia, contrary to the facility's policy on oxygen administration.
A facility failed to maintain safe medication administration practices, resulting in a medication error rate of 5.55%. Errors included not administering prescribed eye drops to a resident, yet documenting them as given. The DON confirmed that medications should not be charted if not administered, and the facility's policy requires timely administration with documentation of any deviations.
The facility failed to ensure safe medication storage, with staff personal items found in medication rooms and expired medication on a cart. Personal belongings were improperly stored in the Sequoia and Redwood/Harmony unit medication rooms, confirmed by LNs and the Administrator. An expired Ipratropium bromide/albuterol was found on a medication cart, posing risks of reduced effectiveness and adverse reactions, as confirmed by LN 7 and the DON.
A resident admitted with bronchiectasis and migraines did not receive necessary medications due to facility failures. Cefiderocol, required for infection, was delayed due to pharmacy order issues, and Sumatriptan for migraines was unavailable, leading to unrelieved pain. The facility did not adhere to its policies on admissions and medication shortages.
A facility failed to inform a resident's responsible party of the discharge appeal process. The resident, unable to make health care decisions due to severe dementia, signed her own discharge notice. The case manager did not verify the resident's decision-making capacity before obtaining her signature, contrary to facility policy. The responsible party was not informed of the appeal rights, potentially affecting the resident's access to necessary services.
A resident with severe dementia and a high fall risk suffered a hip dislocation after falling in a facility. The care plan lacked specific interventions like fall mats and a low bed position, contributing to the incident. Staff interviews revealed inconsistent adherence to fall prevention measures, despite awareness of the resident's risk.
A resident with Parkinson's disease fell from his wheelchair, resulting in the loss of his front teeth. Despite visible injuries and the resident's report of pain, the nursing staff failed to conduct an oral assessment or inform the physician about the potential dental damage. This oversight led to the resident experiencing pain, difficulty eating, and weight loss.
A resident missed 6 doses of dronabinol and 3 doses of vitamin B6 due to the facility's failure to acquire the medications from the pharmacy in a timely manner. The resident had severe protein calorie malnutrition and moderate cognitive impairment. The facility did not follow its policy for promptly ordering and delivering new medications.
A resident with diabetes experienced a low blood sugar episode, and the facility failed to follow the physician's orders for treatment. The nurse administered orange juice instead of glucagon gel, did not notify the physician, and did not recheck the blood sugar every 15 minutes as required.
Food Storage and Equipment Deficiencies
Penalty
Summary
The facility failed to provide food preparation and storage in accordance with professional standards for the 67 residents who ate facility-prepared meals. During a kitchen tour, surveyors found one box of carrots in the freezer without an open date. The Certified Dietary Manager (CDM) confirmed the box should have had an orange label with an open date, and stated that food items needed to be labeled properly because once a product is opened and exposed to air it begins to deteriorate. The facility policy titled Production, Purchasing, Storage stated that unused portions and open packages must be covered, labeled, and dated, and that items should be rotated using first in, first out. Surveyors also found one tote of thickener powder with an expiration date of 6/18/26. The CDM confirmed the thickener powder should have been discarded after its expiration date and stated it should have been thrown away when it expired. The CDM stated that expired thickener powder would not thicken food properly and could put residents at risk of aspiration. The facility policy stated that foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded and that food past the use-by or expiration date should be discarded. In addition, surveyors observed four non-stick fry pans with signs of overuse, including scratches, discoloration, dents, and worn coating, and a blender food stirring rod with deep gouges and a missing piece of plastic. The CDM confirmed the fry pans and blender rod were overly used and should have been replaced. The CDM stated staff were using metal spatulas with the non-stick pans instead of the designated high-temperature plastic spatulas, and that scratched pans could lead to cross-contamination and Teflon flakes could come off into food. The CDM also stated the damaged blender rod could allow plastic fragments to contaminate food. The FDA Food Code sections cited in the report addressed nonstick coatings and food contact surfaces with imperfections.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to follow infection control practices during care and medication preparation for multiple residents. Resident 93 had diagnoses including Clostridium difficile and was on contact isolation precautions, with a contact precaution sign posted outside the room. During observation, the Resident Assessment Coordinator entered the room without gown and gloves, sat on the resident’s bed, and touched the resident while the resident was under contact isolation precautions. The Treatment Nurse and the DON confirmed the resident was on contact isolation, and the Infection Preventionist stated staff were expected to wear isolation gowns and gloves before entering any contact isolation room. During medication pass for Resident 42, a Licensed Nurse checked the resident’s blood pressure and then immediately prepared medications without performing hand hygiene. The nurse confirmed she did not sanitize her hands after the blood pressure check before handling the medications. The facility’s hand hygiene policy stated that hand hygiene must be performed before preparing or handling medications. During medication preparation for Resident 65, the same nurse prepared aspirin without wearing gloves and picked up a tablet with her bare hands. The nurse stated she should have used gloves, and another nurse later reported the bottle of aspirin used that morning was discarded. In addition, during inspection of the Redwood and Sequoia medication carts, two pill cutters were observed with visible pill residue on the cutting surfaces and inside compartments. The Infection Preventionist, another nurse, and the DON stated pill cutters should be cleaned after each use, and the facility policy stated the splitter blade and surface contacting the tablet are cleaned before and after each use.
Incomplete CGM Orders and Lack of Staff Competency for Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that Resident 6 received treatment and care in accordance with professional standards of practice when the resident’s continuous glucose monitor (CGM) was used without a complete physician order. Resident 6 was admitted with diabetes mellitus and had orders for Semglee at bedtime and Novolin R on a sliding scale before meals and at bedtime. The record also included a general order to change out the CGM sensor as needed, but there was no physician order authorizing the use of the CGM for blood glucose monitoring or directing nursing staff to use CGM readings to determine insulin administration. Resident 6 had a CGM sensor attached to the posterior left arm and stated that the facility’s nursing staff replaced the sensor about every 14 days and relied on the CGM receiver readings when checking blood glucose and giving insulin. Resident 6 also stated that she had not observed finger-stick blood glucose testing being used to verify the quality, accuracy, or reliability of the CGM readings. During record review and interviews, the RAC and an LN confirmed that the facility had no physician order or facility protocol identifying when or how to verify the CGM readings, including comparison with finger-stick testing, and confirmed that the CGM readings were being used for insulin administration without such direction. The facility also had no documentation showing that nursing staff had received in-service education or competency validation for the use and management of the CGM. The DSD stated that the education records showed no training specific to the Libre CGM, and two LNs stated they had not received competency-based education or reviewed the manufacturer’s instructions. The DON stated that the facility did not have a policy or procedure specifically addressing CGM use and management, and confirmed that the resident should have had a complete physician order addressing CGM use, blood glucose monitoring, insulin administration, and other clinical parameters.
Low Air Loss Mattress Set Incorrectly for Resident With Multiple Skin Impairments
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when Resident 94’s low air loss mattress was found set at 180 pounds even though the resident’s documented weight was 106.5 pounds. Resident 94 was admitted with age-related physical debility, need for assistance with personal care, and gait and mobility abnormalities, and had a physician’s order for a low air loss mattress with a care plan addressing risk for impaired skin integrity and use of a pressure reducing mattress. During a concurrent observation and interview, Resident 94 was lying on the low air loss mattress and stated she felt uncomfortable while in bed. The mattress control unit was powered on and functioning, but the weight/pressure indicator was illuminated at the 180-pound setting. Licensed nursing staff confirmed the resident’s current weight did not match the mattress setting and stated the setting needed to be adjusted according to the resident’s body weight. Record review and staff interviews showed the facility did not have specific physician orders or eMAR tasks directing routine nursing checks of the mattress placement, function, or pressure/weight setting. Nursing staff stated they generally relied on alarm or beep sounds from the mattress to identify problems, while maintenance staff stated the mattress should be set using the resident’s current weight and nursing staff were responsible for ongoing daily monitoring. The DON confirmed Resident 94 had multiple skin impairments, including a Stage 3 pressure injury, an unstageable pressure injury, a popped blister, and redness to the left shin, and had a Braden Scale score of 10 indicating high risk for pressure injury development and deterioration.
Incomplete CPAP Order and Setup
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident who used a CPAP machine at bedtime. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, COPD with acute exacerbation, pneumonia, and obstructive sleep apnea. The care plan identified ineffective airway clearance using CPAP at bedtime, with a goal of adequate ventilation and tissue oxygenation and an approach of CPAP as per order. During observation, the resident was seen in bed with the CPAP machine on the bedside drawer, connected to tubing and a humidifier chamber. The resident stated she recently had pneumonia and used the CPAP every night while sleeping, but said she did not know about the setup and that the nurses were supposed to know. Review of the electronic record showed the physician order only stated CPAP at bedtime and did not include the prescribed pressure settings or other specific parameters needed for safe implementation. A nurse confirmed the order was incomplete and stated it should have included the clinical indication, pressure settings, instructions for application and removal, and directions for cleaning, maintenance, and replacement of the equipment. The DON stated physician orders needed to be complete and specific, and that if an order was incomplete or unclear, nursing staff were expected to contact the physician for clarification before implementing treatment. The manufacturer instructions reviewed by the facility also stated that first time setup should not be used until an appropriate professional adjusts the settings.
Medication Supply Management Failure
Penalty
Summary
The facility failed to ensure timely medication reordering and adequate medication supply management for two residents. One resident did not receive the ordered Lidocaine patch on 6/24/26 because it was unavailable during medication pass. During observation, an LN reported the patch was unavailable, and another LN stated the resident had been told it would be reordered. Later that day, the patch still had not been received from the pharmacy. Record review confirmed the patch was not administered on 6/24/26 because it was unavailable, and it was delivered that evening. The resident later had a pain level of 5 on a scale of 1-10 in the right hip when the patch was administered the next morning, and no PRN medication was given. A second resident who receives dialysis did not receive two of three ordered doses of Calcium Acetate because the medication was unavailable and had to be reordered. During medication pass, an LN reported the Calcium Acetate was unavailable, and another LN said the physician would be informed. Record review confirmed the missed doses in the eMAR, with the reason documented as needing re-ordering. The DON stated that unavailability of medications during medication pass did not meet expectations because licensed nurses need to track medication supply and reorder in a timely manner so treatments are not delayed.
Improper storage and labeling of supplies and controlled substances
Penalty
Summary
Opened bottles of sterile packing strips were found in a treatment cart without a date or time indicating when they had been opened. During observation, the Treatment Nurse stated the strips were used by admission nurses and did not know why the opened bottles were in the cart. The Infection Preventionist later stated the bottles were not maintained in accordance with facility policy and posed a risk for cross-contamination and infection. The facility policy required wound dressings to be handled in a safe and sanitary manner to avoid contamination, and required supplies to include labels for date opened and date expires. An opened 100 mL bottle of Normal Saline was also observed in a treatment cart with only the date written on the cap. Nursing staff stated the bottle was used during shifts, reused for up to 24 hours, and in some cases used for multiple residents or carried over to the next shift. The manufacturer’s label on the bottle stated, DO NOT REUSE. Staff and the Infection Preventionist acknowledged that the manufacturer’s instruction meant the bottle was intended for one-time use only, and the facility’s irrigation solution policy stated that the nurse opening the container labels it with the date and time immediately upon opening and that the use period after opening is found on the manufacturer’s label. A SentrySafe vault used to store narcotics awaiting destruction was observed in the DON’s office, and the DON and Administrator confirmed it was not permanently affixed to the wall or floor. The DON stated she was not aware the vault was required to be permanently affixed. The facility policy for controlled substance storage stated that Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications.
Taped Call Light Prevented Resident Access to Assistance
Penalty
Summary
The facility failed to protect a resident from neglect when a CNA placed tape over the reset button on the call light panel in the resident’s room, preventing the call light from functioning. The resident had diagnoses including dementia, UTI, difficulty walking, and legal blindness. The resident’s MDS showed moderately impaired cognition, use of a wheelchair, and need for substantial assistance with toileting, transfers, and other ADLs. Care plans directed staff to keep the call light within reach, answer it promptly, and assist with toileting and transfers. On the day of the incident, a Maintenance Lead entered the resident’s room and found the resident repeatedly pressing the call light while lying in bed. The Maintenance Lead observed tape on the call light reset button, which was holding it down so the call light was not functional for the resident to call for assistance. The Maintenance Lead reported that the resident was blind and could not see that the call light panel was not working. The Maintenance Lead notified the Administrator, and the resident was placed on constant room checks. During interviews, the CNA assigned to the resident stated the resident had been pressing the call light frequently and that she was present when the Maintenance Lead discovered the taped reset button. The CNA denied placing the tape, while the Maintenance Lead stated he saw the tape and later observed the CNA begin to remove it after he pointed it out. Staff interviews reflected that a taped call light reset button would be considered neglect or abuse because it prevented the resident from using the call light to request assistance. The DON stated that residents use call lights to communicate needs and that a nonfunctioning call light due to tape was a form of abuse.
Failure to Provide Functioning Call Light and Alternative Communication
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, resulting in the resident being unable to summon assistance when needed. The call light in the resident's room did not illuminate outside the doorway when pressed, although it did activate the panel at the nurse's station. This malfunction persisted from a Saturday through the following Tuesday, during which time the resident experienced an episode of urinary incontinence because staff did not respond to his call for assistance to the bathroom. The resident, who had a history of pneumonia and lack of coordination, was unable to get up independently to use the bathroom. Interviews with staff revealed that when a call light was broken, the issue was logged for maintenance, but repairs were delayed over weekends. Staff were unaware of alternative methods for residents to call for help when the call light was not working, and the resident was not provided with a hand bell or other means of communication during the outage. Facility policy required that an alternative method, such as individual bells, be provided if the call light system malfunctioned, but this was not implemented. Maintenance records confirmed the call light was reported broken, and an incorrect bulb replacement further delayed the repair.
Failure to Record Soup Temperatures
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not recording the temperature of soup served to eight residents during lunch. On the specified date, during a tray line observation, it was noted that tomato soup was not initially available, prompting dietary staff to heat a pan of soup on the stove. Subsequently, servings of chicken noodle soup were placed on meal trays for the residents. However, there was no recorded temperature check for the soups before they were served, which is a critical step to ensure food safety. The Certified Dietary Manager confirmed that the temperature log for the lunch did not include a temperature check for the soups, acknowledging that this should have been done to ensure the food was in the safe temperature zone. A staff member stated that she typically checks and documents food temperatures before serving, as incorrect temperatures could lead to illness. The facility's policies on time and temperature control, as well as meal temperature, emphasize the importance of recording accurate temperatures to prevent foodborne illness. The failure to record the soup temperatures put the residents at risk for foodborne illness, as it was unknown if the soup was served at a safe temperature.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP). Specifically, signage indicating the need for personal protective equipment (PPE) was not posted on or near the doorway of Resident 335's room, who was on EBP due to staph aureus bacteremia. The Unit Manager/Case Manager and the Infection Preventionist confirmed the absence of the EBP sign, which is crucial for informing staff about the necessary precautions to prevent the spread of infection. Additionally, PPE supplies were not readily available outside the rooms of several residents on EBP, including Residents 14, 35, 42, and 64. These residents had various conditions such as dialysis ports, pressure ulcers, and gastrostomy tubes, which increased their risk of infection. Staff members, including Licensed Nurses and Certified Nurse Assistants, confirmed that PPE supplies were either located inside the residents' rooms or in utility rooms, rather than being immediately accessible outside the rooms as required. The Director of Nursing and the Infection Preventionist acknowledged that the facility's policy and procedure for isolation precautions were not followed, which posed a potential risk for the spread of infection. The lack of proper signage and readily available PPE supplies compromised the facility's ability to effectively implement EBP and protect both residents and staff from infection and cross-contamination.
Resident's Dignity Compromised Due to Delayed Feeding
Penalty
Summary
The facility failed to honor a resident's right to be treated with dignity and respect when a resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed. The resident, who required assistance with feeding due to her condition, was observed seated at a table with her meal while licensed staff fed another resident at the same table. The resident was alert and looking around the room, and later began crying out, yet her meal remained untouched until a licensed nurse began feeding her. At that point, the temperature of the food was recorded at 110 degrees Fahrenheit, which was below the appropriate serving temperature. Interviews with staff revealed that the licensed nurse had placed the meal in front of the resident expecting a CNA student to assist with feeding, but when no one came, the nurse proceeded to feed another resident. The Director of Nurses acknowledged that it was a dignity issue for residents not to eat their meals together and that a fresh meal should have been requested when the delay occurred. The Certified Dietary Manager confirmed that food should be served at temperatures between 145-150 degrees Fahrenheit and that the food served to the resident was inappropriate. Facility policies reviewed indicated that residents needing assistance should be promptly fed and that food should be served at safe and appetizing temperatures.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's rights related to treatment choices were known and protected, as a copy of the resident's Advance Directive was not maintained in their medical record. The resident, who was admitted with diagnoses including aftercare following right hip joint surgery and a fracture of the neck of the right femur, had a Physician Orders for Life-Sustaining Treatment (POLST) form indicating the existence of an Advance Directive. However, upon review, the Advance Directive was neither found in the resident's physical chart nor uploaded into their Electronic Health Record (EHR). Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the absence of the Advance Directive in the resident's records. The SSD and DON both acknowledged that the Advance Directive should have been included in the resident's chart to ensure their treatment preferences were known and could be followed, especially during transfers to other facilities. The facility's policy required that the Advance Directive be obtained and reviewed during the admission process and at least quarterly thereafter, but this was not adhered to in this case.
Resident Privacy Breach Due to Public Posting of Care Instructions
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of Resident 12's personal and medical information. Resident 12, who was admitted with a diagnosis of urinary incontinence, had his incontinence care needs publicly displayed in his room. A handwritten sign and two photos detailing the care instructions for his condom catheter were posted on the bathroom door facing into the room, making the information visible to anyone entering the room. During interviews, a licensed nurse acknowledged that the information was posted to inform staff about the supplies needed for Resident 12's care but admitted that it could have been placed inside the bathroom door for privacy. The Director of Nurses also recognized that the posting of personal information without covering it with a blank page created a dignity issue for the resident. The facility's document on residents' rights emphasized the right to be treated with respect and dignity, which was not upheld in this instance.
Resident Unable to Independently Release Self-Release Belt
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was free from physical restraints. Resident 12, who had been diagnosed with Parkinsonism and unspecified dementia, was observed to be unable to independently unbuckle a self-release belt while seated in his wheelchair. Despite the resident's request for the belt and initial demonstration of its use, during an observation, the resident was unable to release the belt independently, indicating it functioned as a restraint. Licensed Nurse 6 confirmed the resident's inability to release the belt without assistance. The MDS Coordinator acknowledged that Resident 12's condition, affected by Parkinson's disease, impacted his cognition and mobility, and confirmed that the resident's quarterly MDS assessment did not include a reassessment of the self-release belt, which should have been conducted. The facility's policy emphasizes a restraint-free environment unless medically necessary, and the resident's inability to remove the belt independently classified it as a restraint. The facility's failure to reassess the need for the belt and ensure the resident's ability to release it independently led to the deficiency.
Failure to Develop Oxygen Use Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident's oxygen needs, which led to the resident receiving an incorrect rate of oxygen. During an observation and record review, it was confirmed that the resident was receiving oxygen at 2.5 liters per minute (LPM) instead of the prescribed 4 LPM continuously. The Licensed Nurse (LN) confirmed the discrepancy and acknowledged that a care plan should have been in place to guide the nursing staff in administering the correct oxygen rate. Further interviews and record reviews with the Director of Nursing (DON) confirmed that no care plan was created for the resident's oxygen use. The DON emphasized the importance of a care plan in providing nurses with interventions and guidance to prevent such errors. The absence of a care plan potentially contributed to the resident receiving insufficient oxygen, which could lead to complications such as shortness of breath.
Inadequate Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident 71, who was admitted with multiple diagnoses including sepsis and bilateral hydronephrosis. During an observation, it was noted that Resident 71's urinary catheter bag was placed on the floor and lacked a dignity cover. This was confirmed by Licensed Nurse 1, who acknowledged that the catheter bag should not be on the floor due to the risk of contamination and should be covered to maintain the resident's dignity. Licensed Nurse 2 also confirmed that the catheter bag should be placed below the bladder and attached to the bedrail when the resident is in bed, and should have a dignity cover. The Director of Nursing (DON) stated that the staff is expected to ensure urinary catheter bags are off the floor and covered at all times to prevent infection and protect resident dignity. The facility's policy on indwelling catheters also indicated that catheter bags should be covered to maintain resident dignity. The Centers for Disease Control and Prevention guidelines for preventing catheter-associated urinary tract infections also specify that catheter bags should not rest on the floor. These failures had the potential to affect Resident 71's sense of self-worth and self-esteem and placed the resident, and others in the facility, at risk for adverse medical outcomes.
Failure to Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who was receiving oxygen therapy. During an observation, it was noted that the resident was receiving oxygen at a rate of 2.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 4 LPM. This discrepancy was confirmed by a licensed nurse who acknowledged that the oxygen order was not being followed as prescribed. The Director of Nursing also confirmed that the ordered amount of oxygen for the resident was 4 LPM continuously. The failure to administer the correct oxygen dosage placed the resident at risk for hypoxia, which is a condition where there is insufficient oxygen supply to the body's tissues. The facility's policy on oxygen administration, which requires licensed nurses to carry out oxygen therapy orders, was not adhered to in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 5.55%, which is above the acceptable threshold of 5%. This was observed during medication administration to a resident, where two errors occurred out of 36 opportunities. Specifically, the errors involved the failure to administer dorzolamide-timolol and Restasis eye drops to a resident as prescribed. Despite not administering these medications, the licensed nurse documented them as given at the scheduled time. During an interview, the Director of Nursing acknowledged that medications should not be charted as given if they were not administered. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, and any deviations should be documented with an explanatory note. The failure to adhere to these practices had the potential to result in unsafe medication use and affect the resident's health and well-being.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during inspections of the medication storage rooms and medication carts. In the Sequoia unit medication room, personal items belonging to staff, such as an opened partial bottle of water, coffee cups, tote bags, and a staffing schedule, were found stored under the sink. Similarly, in the Redwood/Harmony unit medication room, personal items including a water bottle, backpack, lunch box, and another personal bag were found on the countertop and under the sink. Both Licensed Nurses (LN 4 and LN 5) confirmed the presence of these items and acknowledged that staff personal belongings should not be stored in medication rooms or under sinks. The Administrator also confirmed that staff personal belongings were not allowed in these areas. Additionally, an inspection of medication cart #2 on the Sequoia unit revealed an expired medication, Ipratropium bromide/albuterol, which was found with an opened date exceeding the recommended two-week usage period after opening. LN 7 confirmed the medication was expired and should have been removed from the cart, acknowledging the risk of reduced effectiveness and potential adverse reactions if administered to residents. The Director of Nursing (DON) stated that the expectation was to remove the medication 14 days after opening, as per the facility's medication storage policy, which emphasizes proper storage and organization of medications.
Failure to Provide Necessary Medications for Resident
Penalty
Summary
The facility failed to provide necessary medications for a resident, leading to potential prolonged illness and unrelieved pain. The resident was admitted with conditions including bronchiectasis with pseudomonas/klebsiella infections and migraines. The resident required intravenous Cefiderocol every 8 hours, but the medication was unavailable at the scheduled times due to a delay in the pharmacy receiving the infusion order request. The Director of Nursing (DON) had to approve medications above certain price points, and the approval for Cefiderocol was not given until the day after the resident's admission. Additionally, the resident required Sumatriptan for migraine headaches, which was also unavailable. The pharmacy informed the facility that the medication was temporarily out of stock and suggested an oral alternative if a doctor's order was obtained. However, there was no documentation that the medical doctor was informed of this request on the day it was made. Consequently, the resident experienced unrelieved pain, as the alternative narcotic pain reliever administered was ineffective. The facility's policies on admissions and medication shortages were not adhered to, as the facility admitted a resident whose needs could not be met and failed to ensure the availability of ordered medications. The DON confirmed that the nurse should have informed the medical doctor of the medication request, and the lack of available Sumatriptan led to the resident experiencing unrelieved pain.
Failure to Inform Resident's Representative of Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure a resident's right to be fully informed of her discharge and the possibility for appeal was protected. Resident 1, who was deemed unable to make health care decisions due to severe unspecified dementia, signed her own discharge notice. The resident's responsible party was not informed of the discharge appeal process, which is a requirement when a resident is unable to make their own health care decisions. The resident's advance health care directive designated her husband as her agent for health care decisions, with her daughter and son as alternates, effective when her primary physician determined she was unable to make her own decisions. A physician order dated shortly before the discharge confirmed that Resident 1 was not capable of making her own health care decisions. The case manager admitted to not verifying Resident 1's decision-making capacity before having her sign the discharge paperwork, despite usually reviewing physician orders for such information. The facility's policy requires that residents and/or their representatives be provided with written notice of an impending transfer or discharge, including a statement of the resident's appeal rights. However, the documentation did not indicate that the responsible party was informed of the right to appeal the discharge decision. This oversight resulted in the responsible party being uninformed of the appeal rights, potentially affecting the resident's access to necessary services if an appeal was sought and upheld.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate measures to prevent injury from falls for a resident who was at high risk for falling. The resident, who had severe dementia and was recovering from a hip hemiarthroplasty, was assessed with a high fall risk score. Despite this, the care plan did not include specific interventions such as the use of fall mats or ensuring the bed was kept in a low position. This oversight contributed to the resident sustaining a complete dislocation of the right hip after a fall. On the day of the incident, the resident was found on the floor with a dislocated hip, which required hospital readmission and surgical intervention. Interviews with staff revealed that the resident's bed was often left in a high position, contrary to the care plan's directives. The staff, including CNAs and licensed nurses, were aware of the resident's fall risk but failed to consistently implement the necessary precautions, such as keeping the bed low and using fall mats. The facility's policies on fall prevention and care planning were not adequately followed, as evidenced by the lack of specific interventions in the resident's care plan. The interdisciplinary team did not incorporate all identified risk factors into the care plan, which should have included measures to prevent falls and potential injuries. This failure to adhere to established protocols resulted in the resident's fall and subsequent injury.
Failure to Provide Dental Care After Resident's Fall
Penalty
Summary
The facility failed to provide necessary dental care for a resident who experienced an unwitnessed fall, resulting in the loss of his front teeth. The resident, who was admitted with Parkinson's disease and required assistance with personal care, fell from his wheelchair and was found bleeding from the mouth. Despite the visible injuries and the resident's report of pain and missing teeth, no oral assessment or follow-up dental care was provided. The nursing staff, including a Certified Nurse Assistant and a Licensed Nurse, observed the resident's injuries but did not take appropriate action to assess the dental damage or inform the physician about the potential loss of teeth. The Licensed Nurse admitted to not being sure about the resident's dental status prior to the fall and failed to communicate the possibility of lost teeth to the doctor. This lack of communication and assessment led to the resident experiencing pain and difficulty eating, which potentially contributed to weight loss. Interviews with family members and a speech therapist confirmed that the resident had a full set of teeth before the fall. The Director of Nursing acknowledged the expectation for nurses to notify the physician and representative party about such incidents and the importance of conducting a thorough oral assessment. The failure to assess and address the resident's dental needs after the fall had a negative impact on his well-being and quality of life.
Failure to Administer Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure that medications ordered by the physician were administered to a resident when dronabinol and vitamin B6 were not acquired from the pharmacy in a timely manner. This resulted in the resident missing 6 doses of dronabinol and 3 doses of vitamin B6. The resident, who was admitted with severe protein calorie malnutrition and had undergone gastric bypass surgery, had a BIMS score indicating moderate cognitive impairment. The missed doses were documented in the Medication Administration Record (MAR) as being unavailable and pending delivery from the pharmacy. During an interview and record review, a Licensed Nurse confirmed that there was no follow-up phone call to the pharmacy or the physician documented in the resident's record. The nurse stated that nursing staff should have contacted the physician to get an order to hold the medications until they were delivered. The facility's policy indicated that new medications should be promptly ordered and delivered to avoid delays in administration, but this procedure was not followed in this case.
Failure to Follow Physician's Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. On 5/16/23, a Licensed Nurse (LN) administered orange juice to a resident with a low blood sugar reading of 59 mg/dL instead of the physician-ordered glucagon gel. Additionally, the LN did not notify the resident's physician of the low blood sugar reading as required by the physician's order and did not recheck the resident's blood sugar level every 15 minutes until it reached at least 110 mg/dL. These actions were not in compliance with the physician's orders and the facility's policy on administering drugs and treatments only upon the order of a licensed and authorized prescriber. The resident, who was admitted to the facility with a diagnosis of diabetes and had a moderate cognitive impairment, experienced a low blood sugar episode. The nurse's progress notes indicated that the resident's blood sugar levels were rechecked only twice from 8:51 a.m. to 2 p.m., instead of every 15 minutes as required. The blood sugar levels did not reach the target of 110 mg/dL. During an interview, another LN confirmed that the physician's orders were not followed, and the facility's policy was not adhered to in this instance.
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 599 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 Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Creek Post-acute | 0.6 mi | ★★★★★ | 27 | 0 |
| Creekside Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Delta Oaks Post Acute | 2.6 mi | ★★★★★ | 20 | 0 |
| Crestwood Manor - 104 | 3.7 mi | ★★★★★ | 3 | 0 |
| Brookside Care Center | 3.8 mi | ★★★★★ | 74 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.