Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Meadows Ridge Care Center during CMS and state inspections, most recent first.
Incomplete Medication Destruction Documentation: The facility failed to keep accurate medication destruction records when nine disposed medications were documented without the required second licensed nurse witness signature on the Medication Disposition Record/Pass Log. During review with the DON and RN Supervisor, the missing signatures were confirmed, and the DON acknowledged the facility’s policy requiring non-controlled medication destruction in the presence of two licensed nurses was not followed.
Dirty dishware and unclean storage surfaces were found in the kitchen, including aluminum dishes with food debris and grease buildup and a shelf with dried and greasy residue where clean dishware was stored. The dietary cleaning log showed multiple days with no documentation or only partial documentation of required daily cleaning, and staff could not explain the missing entries. In addition, eight cups of milk-like liquid were found in the refrigerator with no date or label, contrary to the facility’s dating and labeling policy.
Infection control practices were not followed for multiple residents and resident care items. A resident’s oxygen tubing was found unlabeled and undated, a laptop on an IV cart was visibly soiled, and staff did not follow EBP requirements for two residents with indwelling devices when providing high-contact care. An LVN administered G-tube medication without a gown, and another LVN performed a blood glucose check without the required gown, despite posted EBP signage and facility policy requiring gown and glove use.
A resident with anxiety, HF, SOB, and DM was ordered lorazepam PRN for anxiety, but the facility could not produce a signed informed consent for psychotherapeutic drugs. The Case Manager stated informed consent did not appear to have been obtained before the medication started, and the resident said the provider did not discuss the side effects, risks, or benefits of the anti-anxiety medication. The DON confirmed the facility policy was not followed and that the consent documentation should have been in the chart.
A resident with aphasia, epilepsy, anxiety disorder, schizoaffective disorder, and leukemia was identified as at risk for wandering/elopement, but he left the facility unattended and was later found in a parking lot near a gas station. Staff last saw him in the hallway, and video showed him exiting through the front door while the front desk was unattended because the assigned staff member had called off.
A resident with ESRD and an AV fistula had missing Q shift dialysis access monitoring in the MAR for bleeding, swelling, pain, bruit, and thrill, and the Dialysis Communication Record was incomplete for pre- and post-dialysis assessment. The record also listed the wrong access site, and the ADON and DON acknowledged the blanks and incorrect documentation.
A resident repeatedly requested her complete medical records from the Medical Records department and DON, receiving only partial records and no responses to follow-up emails. Despite facility policy requiring records to be provided within 48 hours, staff did not fulfill the requests or communicate with the resident, and could not explain the failure to comply.
A resident with multiple health conditions experienced an unwitnessed fall after call lights were not answered for an extended period. Nursing staff failed to document the incident, notify the physician, or monitor the resident post-fall, as required by facility policy. Interviews and record review confirmed the lack of documentation and follow-up.
A facility failed to monitor a resident's blood pressure and heart rate every six hours as ordered by the physician, leading to the resident being sent to the hospital for hypertension. Despite the care plan indicating a risk for cardiac distress, the staff only conducted weekly checks, contrary to the physician's orders.
A resident with depression and anxiety was financially exploited by a staff member who used the resident's EBT card for unauthorized purchases totaling $662.21, violating facility policies. The resident experienced emotional distress, and the incident highlighted a failure to adhere to financial abuse prevention and resident rights policies.
A facility failed to provide adequate personal hygiene care for a resident with multiple medical conditions, resulting in only two showers over nearly a month. There was no documentation of the resident's shower refusals, and the responsible party was not notified. Staff interviews revealed a lack of awareness and documentation regarding the refusals, contrary to the facility's policy.
The facility failed to follow food safety standards by storing expired marshmallows and leaving fruit juices on a resident's bedside table for two days. The Dietary Supervisor and Administrator acknowledged these lapses, which violated the facility's policies on food storage and tray collection.
A facility failed to replace oxygen tubing and supplies for a resident as per its policy, which mandates weekly replacement. The supplies were found to be nine months old, and staff acknowledged the oversight. The resident had conditions including cerebrovascular disease and dementia.
A resident experienced severe weight loss and worsening of a pressure ulcer, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within the required timeframe. The resident's care plan was not updated to reflect her current condition, potentially delaying necessary care. The DON and Administrator acknowledged the oversight during a record review.
A facility failed to timely implement RNA orders for a resident's ROM exercises, delaying the start of prescribed AAROM exercises for both lower and upper extremities. The resident, with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, began receiving exercises a week after the order was written. The RNA Supervisor and DON acknowledged the delay, which was against the facility's policy for timely treatment implementation.
A resident with multiple diagnoses, including a UTI, did not receive a prescribed dose of Ertapenem Sodium due to a delay in pharmacy delivery. The medication was available in the Emergency Kit, but staff failed to administer it, violating the facility's policy for timely medication administration.
A resident with protein-calorie malnutrition, dystonia, and epilepsy did not receive a physician-prescribed diet in a timely manner. The diet order, issued on August 8, 2024, was not implemented until August 26, 2024, despite facility policies requiring timely execution of physician orders. The DON confirmed the delay, which could have risked further nutritional and medical decline.
A CNA in an LTC facility failed to report redness on a resident's nose to the nursing staff, despite facility policies requiring such reporting. The resident had a history of malignant neoplasms and repeated falls. The CNA cited being busy and forgetting to report the condition, which was against the facility's job description and policy. The CNA was subsequently terminated.
A resident with multiple health issues and high risk for skin breakdown developed an open wound on the right pinkie finger. Despite a treatment order for daily wound care, the wound was observed without a dressing, and a treatment was missed. Staff interviews revealed a lack of communication and adherence to the care plan, with the DON and Administrator acknowledging the oversight.
A resident with a history of aggressive behavior was not monitored as required, leading to a physical altercation with another resident. The facility failed to document the resident's whereabouts as per the care plan and physician's orders, which increased the risk of further incidents. The DON acknowledged the lapse in following the facility's policy on resident-to-resident altercations.
The facility failed to follow its policy to ensure timely call light responses, resulting in two residents being left soiled and their activities of daily living not being met promptly. Interviews with CNAs and residents indicated that call lights took hours to be answered during the night shift, despite the facility's policies mandating timely responses and necessary care.
Incomplete Medication Destruction Documentation
Penalty
Summary
The facility failed to maintain accurate records of destroyed medications when nine medications that were disposed of were found with missing witness signatures from a second licensed nurse on one Medication Disposition Record/Pass Log. During a concurrent interview and record review with the DON and RN Supervisor, the January Medication Disposition Record/Pass Log was reviewed and showed nine missing witness signatures of a second licensed nurse. The DON and RN Supervisor acknowledged that the medication disposition record/pass log was incomplete because the second licensed nurse signatures were missing. The facility’s Policy and Procedure titled, Disposal of Medication and Medication-Related Supplies, dated January 2025, was also reviewed and stated that non-controlled medication destruction occurs in the presence of two licensed nurses and that the signatures of witnesses are entered on the medication disposition form. The DON stated the policy was not followed because the second licensed nurse signature was missing.
Dirty Dishware, Incomplete Kitchen Cleaning Logs, and Undated Milk in Refrigerator
Penalty
Summary
Food sanitation and storage practices were not followed in the kitchen when three clean aluminum dishes were found stored under a food prep table with green and brown food debris, brown grease buildup, remnants of lettuce leaf, and crumbs inside them. A shelf under the same food prep table, where clean dishware was kept, also had a white dried substance and greasy black substance with food crumbs on it. During observation, the Consultant Registered Dietician stated the dishes and shelf were not acceptable in that condition and that staff were expected to keep clean dishes and storage areas clean. The facility’s Dietary Cleaning Schedule for January 2026 was reviewed with the Consultant Registered Dietician and the Dietary Service Supervisor. The schedule required daily cleaning of kitchen areas and equipment, with staff to initial tasks once completed and the supervisor to initial after each shift. Review of the schedule showed 12 days with no documentation that kitchen cleaning was completed and 4 additional days with only partial documentation, for a total of 16 out of 28 days with either no documented cleaning or incomplete daily cleaning tasks. The Consultant Registered Dietician and the Dietary Service Supervisor stated they did not know why the cleaning log was not completed, and the facility could not provide other evidence that the kitchen was cleaned as required. In addition, eight plastic cups containing a white liquid resembling milk were found in the refrigerator with no date or label. The Consultant Registered Dietician stated the cups contained milk products and were supposed to be dated when placed in the refrigerator, but she was unsure why they were undated or when they had been prepared. The facility’s Dating and Labeling policy required food items to be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to follow its infection prevention and control practices in multiple instances involving resident care equipment and enhanced barrier precautions. Resident 7 had oxygen nasal cannula tubing attached to an oxygen concentrator that was observed in the hallway and was not labeled or dated, despite a physician order to change the oxygen tubing every night shift on Sunday and as needed. During the observation, an LVN inspected the tubing and stated it should have been labeled and dated. The DON later reviewed the facility’s oxygen administration policy, which required the date, time, and initials to be noted on oxygen equipment when initially used and when changed, and acknowledged the policy was not followed. The facility also had a visibly soiled laptop mounted to an IV cart outside the nursing station on unit one. The laptop had dried white substance on it when observed, and the RN supervisor acknowledged it was dirty. The facility’s cleaning and disinfecting policy identified computers as non-critical resident care items that must be cleaned and disinfected, and the DON confirmed the policy was not followed. Enhanced Barrier Precautions were not followed for two residents with indwelling medical devices. Resident 11 had an order for EBP related to a G-tube, but an LVN administered medication via the G-tube without wearing the required protective gown. The LVN confirmed she did not wear the gown and did not follow the facility’s EBP policy. Resident 32 had EBP ordered related to a Foley catheter, and an LVN entered the room wearing gloves and a mask but without a gown and performed a blood glucose check at bedside. The LVN stated she forgot to put on the gown. The IP and DON both stated the staff did not follow the facility’s EBP policy, which required gown and glove use for high-contact care activities and indicated PPE should be used for residents with wounds or indwelling medical devices.
Failure to Obtain Informed Consent for Lorazepam
Penalty
Summary
Resident 7 was admitted with diagnoses including anxiety, heart failure, shortness of breath, and diabetes. The resident had a physician order dated November 18, 2025 for lorazepam 0.5 mg, one tablet by mouth every four hours as needed for anxiety. During record review and interviews, the facility could not produce a signed informed consent form for psychotherapeutic drugs for Resident 7, and the Case Manager stated that it did not appear the resident received informed consent prior to the start of lorazepam and that no signed informed consent could be found in the chart. During interview, Resident 7 stated that the provider did not discuss the side effects, risks and benefits of the anti-anxiety medication with him and that he had been on the medication for a while. The DON reviewed the facility policy titled Psychotherapeutic Drugs Informed Consent, which required residents and/or their representatives to be fully informed of the benefits, risks, frequency/duration, possible side effects, and alternative approaches before initiation, and required the prescriber to sign an informed consent form. The DON stated the policy was not followed and that Resident 7 should have received informed consent prior to medication administration and documentation should have been in the resident's chart.
Failure to Supervise a Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide supervision to Resident 56 when the resident left the building without staff awareness and was later found down the street in a parking lot near a gas station. Resident 56’s face sheet listed diagnoses including aphasia, epilepsy, anxiety disorder, schizoaffective disorder, and leukemia. The resident’s care plan, dated May 16, 2025, identified a risk for wandering/elopement related to anxiety, schizoaffective disorder, episodes of elopement, poor safety awareness, and impaired cognition, with a goal that the resident would not leave the facility unattended and that safety would be maintained. According to the DON, Resident 56 was last seen by staff at 4:25 PM on January 25, 2026, and the resident’s sister later could not locate him in his room and asked an LVN about his whereabouts at 5:15 PM. Staff then began searching the facility and surrounding area, and the resident was found at 6:03 PM in a parking lot next to a gas station. The DON stated facility cameras showed Resident 56 walking out the front door at 4:39 PM, and that the front desk was unattended at that time because the staff member assigned there had called off. The IDT note documented that the resident had been seen sleeping in his room at the start of the PM shift, then walking in the hallway at 4:25 PM before being reported missing.
Incomplete Dialysis Access Monitoring and Documentation
Penalty
Summary
Resident 88, who had end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, and an AV fistula in the right arm, was found to have incomplete dialysis access monitoring documented by facility staff. The resident’s care plan and physician orders required monitoring of the dialysis access site every shift for bleeding, swelling, pain, bruit, and thrill, but the January 2026 MAR was blank for the day and evening shifts on January 24 for these dialysis monitoring tasks. During interview, the resident stated the nurses did not always check the dialysis access site when he returned from dialysis. The facility also failed to complete the pre- and post-dialysis assessment on the Dialysis Communication Record for the resident’s dialysis treatment. The form for January 23 indicated the resident had a left upper arm shunt/graft, although the active access site was on the right forearm. The pre- and post-dialysis sections were blank for bruit, thrill, and whether there was bleeding at the site. The ADON and DON reviewed the record and acknowledged the blanks and the incorrect access site documentation. The facility’s policy for care of residents receiving renal dialysis required nursing assessment of the shunt area for bruit and thrill, physician orders for Q shift monitoring, and completion of the Dialysis Communication Record with pre- and post-dialysis assessment, including access site, bruit/thrill, and bleeding. The ADON stated staff were supposed to follow the physician’s orders and perform and document the assessments every shift, and the DON stated staff should have completed the assessments thoroughly, but they did not.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
A resident with a diagnosis of polyneuropathy and a BIMS score indicating cognitive intactness requested access to her complete medical records on multiple occasions via email to the Medical Records department and the Director of Nursing. The resident initially received only psychiatric notes after her first request, but subsequent requests for her full medical record, made on several dates, were not fulfilled. The resident also did not receive responses to her follow-up emails regarding these requests. Interviews and record reviews confirmed that the Medical Records staff received the resident's requests and were aware of the facility's policy requiring provision of records within 48 hours, excluding weekends and holidays. Despite this, the staff did not provide the requested records or respond to the resident's repeated communications. The Medical Records staff could not provide a reason for the lack of response or the failure to release the records, and the administrator acknowledged that the policy was not followed.
Failure to Document and Respond to Unwitnessed Fall
Penalty
Summary
The facility failed to follow appropriate procedures after an unwitnessed fall involving a resident with multiple medical conditions, including orthopedic aftercare, lower leg fracture, abnormal gait, diabetes, hyperlipidemia, kidney disease, hypertension, and syncope. The resident reported that call lights were not answered for extended periods, leading him to attempt to get up unassisted during the night, resulting in a fall. A nurse discovered the resident after the fall, but there was no documentation of the incident, no notification to the physician, and no evidence of post-fall monitoring or change of condition assessment. Interviews with nursing staff and review of the resident's records confirmed that the fall was not documented in the progress notes, and required notifications and monitoring were not completed. The Director of Nursing and other staff acknowledged that facility policy required documentation, physician notification, and monitoring after such incidents, but these actions were not taken. The facility was unable to provide any documentation that the required procedures were followed after the resident's fall.
Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications for one of the sampled residents, Resident 4. The licensed staff did not monitor Resident 4's blood pressure and heart rate every six hours as ordered by the resident's physician. This oversight was critical as Resident 4 had a history of hypertension, hemiplegia, type 2 diabetes mellitus, and end-stage renal disease, making them clinically compromised. The care plan for Resident 4 highlighted the risk for cardiac distress and required monitoring of vital signs to prevent unrecognized signs and symptoms of cardiac issues. Despite the physician's orders to administer Hydralazine as needed and monitor vital signs every six hours, the Medication Administration Record showed no recordings of blood pressure and heart rate from February 1 to February 17, except on February 18. The Licensed Vocational Nurse admitted to not checking the blood pressure every six hours, and the Director of Nursing confirmed that the staff was only conducting weekly blood pressure checks, contrary to the physician's orders. This failure resulted in Resident 4 being sent to the hospital for evaluation and treatment due to hypertension.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 4 is no longer in the facility and was discharged 2/18/2025. On 3/5/2025, the DON initiated an in-service to the licensed staff regarding medication administration guidelines and procedures, emphasizing monitoring blood pressure for residents on anti-hypertensive medications as ordered by the physician. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/5/2025, DON/Designee conducted an order and MAR review of all residents on anti-hypertensive medications to ensure all residents with such orders have BP monitoring as ordered by the physician. No additional discrepancies were noted with the same deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. The DON/designee will review new orders for anti-hypertensive medications weekly for 3 months to ensure all residents with orders have BP monitoring in place. How the facility plans to monitor its performance to make sure that solutions are sustained. Reporting and review of the above will occur monthly in QA Meeting with the QA Committee for 3 months.
Financial Exploitation of Resident by Staff Member
Penalty
Summary
The facility failed to protect a resident from financial exploitation by a staff member, leading to a deficiency. The incident involved a resident who was admitted with diagnoses including depression, anxiety, and colonostomy status. The resident voluntarily gave her EBT card and PIN to a staff member, Employee 1, with the condition that purchases should not exceed $600. However, Employee 1 copied the card details and used them to make unauthorized purchases totaling $662.21, violating the facility's policy against accepting money or gifts from residents. The facility's policies on financial abuse prevention and resident rights were not followed, as confirmed by the Administrator and Director of Nursing. The resident experienced emotional distress due to the financial abuse, and the social worker was unaware of the resident's possession of an EBT card. The facility's rules of conduct explicitly prohibit employees from borrowing money or accepting gifts from residents, which Employee 1 violated by using the resident's EBT card for personal gain.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to adhere to its policy regarding the provision of Activities of Daily Living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the facility did not provide adequate personal hygiene care for a resident, as evidenced by the lack of showers and insufficient documentation of shower refusals. The resident, who had multiple medical conditions including cerebral infarction, benign prostatic hyperplasia, neurogenic bladder, urinary tract infection, schizoaffective disorder, and hypertension, received only two showers and 22 bed baths over a period of nearly a month. There was no documentation of the resident's refusals to shower in the care plan or progress notes, and the responsible party was not notified of these refusals. Interviews with facility staff, including the Director of Nursing (DON) and the Director of Staff Development (DSD), revealed a lack of awareness and documentation regarding the resident's shower refusals. The DSD acknowledged that shower refusals should be documented and revisited, but was unsure why this was not done for the resident in question. The DON confirmed that there were no records of shower refusals and was unaware of the resident's refusals, which should have been documented as part of the resident's behavior. The facility's policy, revised in March 2018, mandates that residents unable to perform ADLs independently should receive necessary services to maintain personal hygiene, and any refusals should be documented and communicated to the resident's representative.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by two specific incidents. Firstly, during an inspection of the dry storage room, two unopened one-pound bags of mini marshmallows were found to be 54 days past their expiration date. The Dietary Supervisor acknowledged the oversight and confirmed that the facility's policy, which prohibits the storage of expired food items, was not followed. Secondly, in a resident's room, two cups of fruit juice were found on the bedside table, labeled with a date indicating they were two days old. The Licensed Vocational Nurse confirmed that these juices were from a meal tray and should not have been left overnight. The facility's policy requires that food trays be collected after each meal to minimize the risk of foodborne illness, which was not adhered to in this instance. The Administrator acknowledged the lapse in following the policy.
Failure to Replace Oxygen Supplies as Per Policy
Penalty
Summary
The facility failed to implement proper infection control prevention measures for a resident using oxygen therapy. Specifically, the oxygen tubing and related supplies for a resident were not replaced according to the facility's policy and procedure. The resident, who was admitted with diagnoses including cerebrovascular disease, dementia, and dysphagia, had oxygen supplies that were marked with a date nine months prior, indicating they had not been replaced as required. This oversight was observed during a room inspection, where the oxygen tubing and setup bag were found to be outdated. During an interview, a registered nurse acknowledged that the supplies should have been replaced weekly, as per the facility's policy, which mandates weekly replacement of oxygen tubing and related supplies. The night shift staff was responsible for this task, but it was not completed. The facility's administrator also confirmed that the staff failed to adhere to the oxygen administration policy, which required the weekly replacement of the supplies.
Failure to Complete SCSA for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant decline in condition. This resident, admitted with diagnoses including protein calorie malnutrition and an unstageable pressure ulcer in the sacral region, experienced severe weight loss and worsening of the pressure ulcer. The resident's weight decreased from 133 pounds to 116 pounds over three months, a 12.8% loss, which is considered severe. Additionally, the pressure ulcer increased in size and severity, indicating a significant decline in the resident's condition. Despite these changes, the facility did not conduct the required SCSA, which resulted in the resident's care plan not being updated to reflect her current status. The Director of Nursing (DON) and Administrator acknowledged the oversight during a review of the resident's records, admitting that the assessment completed was a Quarterly Assessment instead of the necessary SCSA. This failure to perform the appropriate assessment potentially delayed the implementation of necessary care and support for the resident.
Delay in Implementing RNA Orders for Resident's ROM Exercises
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), as the Restorative Nursing Assistant (RNA) orders for the resident were not carried out in a timely manner. The resident, who was admitted with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, had physician's orders for Active Assistive Range of Motion (AAROM) exercises for both lower and upper extremities. These orders were intended to be performed multiple times a week as tolerated. However, the resident did not begin receiving these exercises until a week after the initial order was written. During a review of the resident's RNA progress notes and an interview with the RNA Supervisor and the Director of Nursing (DON), it was acknowledged that the RNA orders were delayed. The facility's policy and procedure for physician orders, which requires timely implementation of treatment orders, was not followed. This delay in carrying out the RNA orders could have potentially led to a delay in preventing severe contractures of all extremities for the resident.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to administer medications in accordance with the prescriber's orders and facility policy for a resident who was prescribed an antibiotic for a urinary tract infection. The resident, who was admitted with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, was prescribed Ertapenem Sodium to be administered intramuscularly in the evening for 10 days. However, the Medication Administration Record indicated that the resident did not receive the prescribed dose on the second day of treatment. The nursing progress notes documented that the medication was not administered because it was awaiting delivery from the pharmacy. During a review of the incident, a registered nurse acknowledged that the medication was available in the Emergency Kit and should have been administered from there. The facility's policy, which requires medications to be administered in a safe and timely manner as prescribed, was not followed in this instance.
Delayed Implementation of Physician-Prescribed Diet
Penalty
Summary
The facility failed to ensure that a resident received a diet prescribed by their physician in a timely manner. The resident, who was admitted with diagnoses of protein-calorie malnutrition, dystonia, and epilepsy, had a diet order from their primary care physician dated August 8, 2024, which specified a small quarter-size chopped soft diet with thin liquids. However, there was no documented evidence that this diet order was written and carried out by the facility from August 8, 2024, through August 25, 2024. The diet order was only implemented on August 26, 2024, 18 days after the original order was received. During an interview and record review on October 4, 2024, the Director of Nursing acknowledged that the diet order was not carried out in a timely manner. The facility's policy requires that all physician orders be specific, complete, and supported by a diagnosis or condition, and the Registered Nurse is responsible for ensuring these orders are followed. This lapse in timely implementation of the diet order had the potential to place the resident at risk for further nutritional and medical decline.
CNA Fails to Report Skin Condition
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) demonstrated competency in skills and techniques for a resident, leading to a deficiency. The CNA noticed redness on the nose of a resident, who had been admitted with diagnoses of malignant neoplasms of the stomach and kidney, as well as a history of repeated falls. Despite observing the redness, the CNA did not report it to the licensed vocational nurse (LVN) or the registered nurse (RN), citing being busy and forgetting to inform the licensed staff. This inaction was contrary to the facility's job description for CNAs, which requires them to observe and report skin conditions. The LVN and RN were also interviewed, with the LVN assuming the redness was already identified due to the resident's behavior of hitting her face, and the RN stating he was not informed until later. The facility's policy and procedure on changes in a resident's condition or status, which mandates prompt notification of changes to the resident's medical condition, was not followed. The administrator confirmed that the CNA did not adhere to the job description or policy, leading to the CNA's termination.
Failure to Provide Wound Care for High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who developed an open wound on the right pinkie finger. The resident, who was admitted with multiple diagnoses including enterocolitis, mononeuropathy, muscle weakness, and protein-calorie malnutrition, was identified as high risk for skin breakdown. Despite a wound care order dated September 18, 2024, which specified daily treatment with Xeroform and foam dressing, the wound was observed without a dressing on September 24, 2024. The Treatment Administration Record for September 23, 2024, also indicated a missed wound treatment. During observations and interviews, it was noted that the resident's wound was exposed, with blood smearing between the fingers, and no dressing was applied as ordered. The CNA and LVN acknowledged the absence of the dressing, with the LVN unsure why the treatment was not administered. The Director of Nursing and the Administrator confirmed the oversight, recognizing the resident's high risk for skin breakdown and the need for staff education. The facility's policies on wound care and pressure injury prevention were reviewed, highlighting the requirement for proper wound management and reporting.
Failure to Monitor Resident with Aggressive Behavior
Penalty
Summary
The facility failed to ensure proper supervision and monitoring of a resident who had a history of aggressive behavior. This deficiency was identified when the resident, who had been diagnosed with bipolar disorder, Alzheimer's disease, and anxiety disorder, was involved in a physical altercation with another resident. The resident's care plan and physician's orders required monitoring of the resident's whereabouts every two hours to prevent such incidents. However, the facility did not adhere to these orders, as evidenced by missing documentation of the resident's whereabouts on multiple occasions. The Director of Nursing (DON) confirmed that the monitoring was not conducted as required and acknowledged that the facility's policy on resident-to-resident altercations was not followed. The policy mandated documentation of all interventions and their effectiveness, which was not done in this case. The lack of adherence to the care plan and physician's orders increased the risk of further altercations, potentially leading to injuries and bodily harm.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to follow its policy and procedure to ensure call lights were answered in a timely manner, which resulted in two residents being left soiled and their activities of daily living not being met promptly. Resident 1, who has diagnoses including osteoarthritis, spinal stenosis, polyneuropathy, hemiplegia, and depression, reported that call lights took two hours to be answered at night, leaving them soiled and fearful of developing urinary tract infections. Similarly, Resident 2, diagnosed with multiple sclerosis, paraplegia, obesity, hyperlipidemia, hypotension, and overactive bladder, stated that call lights took hours to be answered, resulting in them sitting on soaking wet waterproof pads for extended periods. Interviews with CNAs corroborated these complaints, indicating that residents often complained about long wait times for call light responses during the night shift. The facility's policy and procedure documents, including those for Activities of Daily Living, Answering the Call Light, and Resident Rights, were reviewed and found to mandate timely responses to residents' needs and the provision of necessary care to maintain good hygiene and dignity. Despite these policies, the administrator claimed to be unaware of any complaints regarding delayed call light responses. This discrepancy between policy and practice highlights a significant lapse in the facility's adherence to its own standards, potentially compromising resident safety and well-being.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Colton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Canyons Post-acute | 0.6 mi | ★★★★★ | 8 | 0 |
| Grand Terrace Health Care Center | 1 mi | ★★★★★ | 5 | 0 |
| Heritage Gardens Health Care Center | 2.9 mi | ★★★★★ | 18 | 0 |
| Loma Linda Post Acute | 2.9 mi | ★★★★★ | 0 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 3.8 mi | ★★★★★ | 10 | 0 |
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