Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Hidden Lakes Senior Living Community during CMS and state inspections, most recent first.
Menu and recipe deviations were observed during meal service when staff served items that did not match the posted lunch menu or the documented recipes for beef quesadilla and savory baked chicken thigh. The CDM also added mashed potatoes and gravy to the alternate meal without the required documentation, and two residents voiced complaints about poor food quality, limited variety, and cold breakfast items.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors observed multiple sanitation issues, including a dirty beverage dispenser tray, food debris on storage surfaces and floors, an opened bag of macaroni in dry storage, residue on equipment and shelving, a dirty rag stored next to clean glasses, and debris in the knife holder. The CDM confirmed the findings, and photographic evidence was obtained.
Dumpster Area Not Kept Clean and Sanitary: During an observation with the CDM and ESD, two dumpsters at the back of the building were surrounded by a wooden fence, and spilled debris and food were seen on the ground in front of the fence and inside the fence in front of each dumpster. Photographic evidence was obtained, and the ESD stated, "I'll get someone to clean this up."
Cold food and milk were served during meal service. During tray line observation, dietary staff prepped cold items on all trays at once while hot foods were plated separately, used open metal tray carts without insulation, and measured milk on two trays at 50 F and 55 F, above the safe cold holding temp. Two cognitively intact residents also reported that breakfast items, including scrambled eggs, were usually cold or ice cold, and one resident with complex medical conditions said the facility's food was served cold.
Food was not prepared to meet ordered diet textures for several residents. A resident with a mechanical soft diet with chopped meats and another resident with the same order were served sliced roast beef on white bread that was not chopped, and a third resident whose ticket directed bite-size meat received meat that was not cut up or was left in large chunks. During tray line observation, the cook also failed to prepare mechanically altered meat as directed on the meal ticket, and staff did not compare trays with meal tickets during service.
Inaccurate MDS assessments were identified for two residents. One resident with quadriplegia and hospice services had MDS entries showing no lower-extremity impairment and conflicting documentation about terminal prognosis, while the DON could not explain the inconsistency. Another resident with bilateral foot drop had an MDS showing no lower-extremity impairment despite record documentation of the condition and therapy notes showing ambulation with AFO braces.
Failure to assess and notify for change in condition; antihypertensive given without required BP check. A resident with atrial fibrillation and septicemia repeatedly reported cold-like symptoms, poor appetite, nausea, and feeling hot and cold, but the chart showed no timely RN assessment, MD notification, or diagnostic testing documented while symptoms continued. In addition, the resident’s Metoprolol order required holding the dose for low BP, yet BP was not consistently documented before administration and the medication was given once when the diastolic BP was below the ordered hold parameter.
Failure to supervise and implement fall-prevention interventions led to a resident sustaining 3 falls within 5 weeks. The resident had metabolic encephalopathy, HTN, muscle weakness, peripheral neuropathy, and moderate cognitive impairment, yet fall risk assessments rated the resident as low risk and did not include key diagnoses. The care plan called for close observation, frequent checks, and keeping the resident visible, but the DON confirmed the resident fell in the afternoon/evening when most alert, sometimes slid out of the wheelchair to gain attention, and that new staff did not know the resident well enough to provide proper supervision.
A resident with chronic dysphagia received nutrition via a feeding tube, but staff did not follow the MD order for the prescribed water flush amount and did not complete ordered weekly weights. During observation, an RN flushed the tube with less water than ordered, and the DON later acknowledged that the weekly weight order was not carried out as written.
A facility failed to provide food items and portions according to resident preferences for two residents. One resident who was totally dependent for eating and on a mechanically altered diet did not receive daily mashed potatoes or chocolate ice cream listed on the menu ticket, and a tray line check confirmed mashed potatoes were unavailable. Another resident with intact cognition and a mechanical soft diet with double protein was served the same amount of meat as other residents, and a cook later acknowledged the portion had not been prepared as ordered.
The facility failed to ensure a clean and homelike environment, with surveyors observing dirty carpets in three rooms and a missing bolt from a bedside table in one room. The Housekeeping Supervisor mentioned plans to replace the carpet, but the Executive Director had not yet obtained quotes for new flooring. The Executive Director confirmed the issues during a tour with the survey team.
A facility failed to ensure an accurate MDS assessment for a resident regarding medication usage. The MDS documented antidepressant use, but the MAR showed no such provision. Instead, the resident received Clopidogrel and Buspirone, which were not documented in the MDS. The MDS Coordinator confirmed the inaccuracy.
The facility failed to provide scheduled showers and timely nail care for residents, as observed in three cases. A resident with multiple health issues had not received a shower since admission, despite being scheduled for twice-weekly showers. Another resident with moderate cognitive impairment had only one shower in 30 days, and a new admission had not received any showers. The Director of Nursing acknowledged issues with staffing and documentation, leading to inadequate care.
A consultant pharmacist did not identify the absence of behavior monitoring for a resident on Buspirone, Haloperidol, and Ativan. The resident's records lacked documentation of behavior monitoring, and monthly pharmacy reviews from February to July did not address this issue. The pharmacist was informed but did not provide further information to the DON by the exit conference.
The facility failed to monitor medications for two residents, leading to deficiencies. One resident on psychotropic medications lacked documented behavior monitoring, possibly due to an oversight during readmission. Another resident received an ineffective antibiotic, Cipro, for a UTI, as the culture results indicating resistance were not reviewed, resulting in 22 extra doses being administered.
The facility failed to provide timely lab services for two residents, resulting in missing or delayed test results. A resident's CBC and CMP were not drawn as ordered, and another resident's urinalysis was not completed, with the CBC and CMP conducted three days late. The DON cited issues with electronic record integration, and the RN suggested possible labeling or timing errors.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter, leading to a deficiency in infection prevention and control. The resident was observed without an EBP sign and no gowns available, and staff interviews revealed a lack of awareness of the EBP policy. The Director of Nursing confirmed no in-services were conducted following the implementation of a new policy, resulting in inconsistent application of EBP.
The facility failed to post an accurate and current menu for residents, leading to confusion about meal offerings. The daily menu was outdated, and the weekly menu displayed incorrect dates. A resident's significant other expressed confusion, and the Certified Dietary Manager, upon returning from vacation, acknowledged the oversight and corrected the menu.
Menu and Recipe Deviations During Meal Service
Penalty
Summary
The facility failed to follow the posted menu and documented recipes for one observed meal service. On 02/04/26, the lunch menu listed beef quesadilla with Spanish rice, corn, wheat bread, and a sugar cookie as the main meal, and savory baked chicken thigh with roasted carrots as the alternate meal. During tray line observation, staff sent beef quesadillas, chicken thighs, mashed potatoes, and gravy to the steam table. The cook stated she used regular ground beef and peppers only for the quesadilla, rather than the beef fajita strips, shredded mild cheddar cheese, green chilies, onions, and taco seasoning listed in the recipe. She also stated she did not use the biscuit mix or parmesan cheese required for the savory baked chicken thigh recipe. Another cook stated staff sometimes used whatever ingredients were on hand and selected a different recipe from the binder instead. The Certified Dietary Manager added mashed potatoes and gravy to the alternate meal because she felt the meal needed a starch, and said she spoke with the RD, but no documentation of the substitution or recipe alteration was provided. Resident #7, who had a BIMS score of 15 and was cognitively intact, stated the food was bad and did not taste good. A second resident, admitted with depression and a BIMS score of 10 indicating moderate cognitive impairment, complained that the food was not good, that there was little variety, and that the same foods were served frequently. He also reported cold scrambled eggs, and on observation he left part of his breakfast uneaten while stating, "It's the food here."
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. During an observation of the kitchen with the Certified Dietary Manager, surveyors found a brown thick liquid substance in the beverage dispenser tray, a brown liquid spillage and loose dry macaroni noodles on the clear plastic cover of a box containing three cans of chicken and dumplings, an opened bag of macaroni noodles in dry storage, and food crumbs along the side of clean plastic cups stored on a three-shelf rolling cart. Additional findings included debris and food crumbs on the floor beside the ovens and around the feet of all stainless-steel tables, non-smooth surfaces along the legs and shelving edges of all stainless-steel tables that could not be properly cleaned, a black substance near the cutting edge of the can opener, residue on the metal shelf by the scale and silverware holder, a chipped microwave door and framing, a dirty used kitchen rag left on a rolling cart shelf next to a tray of clean glasses, a grease-like substance on the outside of a box of carrots in the walk-in refrigerator, and crumbs and food debris in the knife holder. Photographic evidence was obtained.
Dumpster Area Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary condition. During an observation of the dumpster area with the Certified Dietary Manager and the Environmental Service Director, two dumpsters were seen at the back of the building with a wooden fence around them, and spilled debris and food were observed on the ground in front of the fence and inside the fence in front of each dumpster. Photographic evidence was obtained, and the Environmental Service Director stated, "I'll get someone to clean this up."
Cold Food and Milk Served During Meal Service
Penalty
Summary
Food and drink were not served at a safe and appetizing temperature during the lunch meal service. During a tray line observation, dietary staff prepared cold items, including milk, on all trays at one time for both the skilled nursing and assisted living residents while hot foods were being plated separately. The facility used open metal tray carts rather than closed, insulated carts, and no metal inserts or cart covers were used. The cook began plating at 12:20 PM after hot foods had been reheated, and the Certified Dietary Manager checked the trays as they were completed. When milk temperatures were taken on trays that would have gone to two residents, one measured 50 degrees F and another measured 55 degrees F, both above the safe cold holding temperature of 41 degrees F or below. Resident interviews also reflected ongoing complaints about cold food. One cognitively intact resident stated scrambled eggs were cold as usual and said the food was usually cold, including during breakfast on another day when the eggs were described as ice cold. Another resident with diagnoses including atrial fibrillation and septicemia, and a BIMS score indicating cognitive intactness, reported that the facility's food was served cold and that she disliked cold food. The cook stated milk had been put in the freezer before service and acknowledged that she would need to go back to putting milk on ice while in the kitchen, and explained that trays were being prepped all at once because only one aide was available to help deliver carts.
Mechanical Soft Meals Not Prepared to Ordered Texture
Penalty
Summary
Food was not prepared in a form designed to meet individual resident needs during lunch service and tray line preparation. On 02/02/26, a lunch observation in the main dining room showed four residents being served roast beef sandwiches, and staff did not compare the meals with the meal tickets. After the meal service, the cook confirmed that no ground meat had been prepared for the meal and no cut-up meat had been served for the sandwiches. Resident #2, whose physician order dated 10/27/25 specified a mechanical soft diet with chopped meats, was served sliced roast beef on white bread that had not been chopped. Resident #21, whose physician order dated 10/31/25 specified a mechanical soft diet with chopped meats and whose MDS documented a BIMS score of 6 with partial to moderate assistance needed for eating, was also served sliced roast beef on white bread that had not been chopped. Resident #21’s meal ticket listed a mechanical soft diet but did not include the instruction for chopped meats. Resident #5, whose meal ticket directed that meat be cut up to bite-size pieces and whose MDS documented a BIMS score of 3 indicating severe cognitive impairment, was served a roast beef sandwich with sliced roast beef that had not been cut up at all. A later lunch observation on 02/03/26 showed Resident #5’s meat had been cut up, but two of the pieces remained in large chunks larger than bite size. During a tray line observation on 02/04/26, the cook plated seven mechanically altered meals, and the Certified Dietary Manager checked the meals as they were completed. The CDM instructed the cook to cut up a whole chicken thigh into bite-size pieces for Resident #5, and the cook questioned the instruction, stating that was what the meal ticket said. The cook also stated during interview that the tray line process was usually completed by only the dietary aide and herself.
Inaccurate MDS Assessments for Resident Conditions and Hospice Status
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 2 of 10 sampled residents. For Resident #7, the record showed diagnoses of quadriplegia and hospice enrollment beginning 01/31/25, with a physician-signed Certificate of Terminal Illness renewed each certification period. However, the current Annual MDS and Quarterly MDS documented no impairment to the lower extremities and listed quadriplegia, and the Quarterly MDS and Significant Change assessment for hospice also stated the resident was on hospice services but did not have a terminal prognosis. During interview, the DON stated the resident could not stand or walk but was not a quadriplegic and had no explanation for the contradiction between hospice services and the lack of a documented terminal illness on the MDS assessments. For Resident #6, the medical record documented bilateral foot drop. The Quarterly MDS documented no impairment to the lower extremities and listed difficulty walking. A progress note documented the resident was able to walk with the therapist using bilateral AFO braces. During interview, the DON was unable to explain the discrepancy between the record and the MDS documentation and agreed with the finding.
Failure to Assess and Notify for Change in Condition; Antihypertensive Given Without Required BP Check
Penalty
Summary
The facility failed to timely assess, monitor, document care, and notify the physician when a resident with a history of atrial fibrillation and septicemia began reporting cold-like symptoms and feeling unwell. The resident was observed over several days with a runny nose, nasal congestion, sneezing, coughing, alternating feelings of hot and cold, nausea, poor appetite, and repeated wiping of her nose with tissues. During this time, the clinical record showed no documentation that the physician had been notified, no evidence that the resident had been assessed or treated for the symptoms, and no documentation that diagnostic testing had been performed for a possible respiratory infection. The resident continued to report that she was not feeling well and was not eating meals because of her symptoms. Staff interviews showed the incoming RN had received report that there were no changes in the resident’s condition and no new complaints, despite the resident’s ongoing symptoms. The DON stated that when a resident exhibits cold-like symptoms, nurses are expected to assess the resident and notify the physician, and that diagnostic testing such as laboratory work and a chest x-ray may be initiated based on infection surveillance criteria. The resident later stated she was finally receiving treatment, and contact precautions were placed on the door. The facility also failed to follow a physician order for Metoprolol Tartrate 25 mg daily, which required holding the medication if systolic blood pressure was less than 100 mmHg or diastolic blood pressure was less than 55 mmHg. Review of the MARs and TARs showed blood pressure was not consistently monitored and documented before administration, and on one occasion the medication was given when the resident’s diastolic blood pressure was 52 mmHg. The DON acknowledged the finding and stated the medication order format did not prompt nurses to document blood pressure readings.
Failure to Supervise and Prevent Repeated Falls
Penalty
Summary
The facility failed to ensure supervision and implementation of interventions to prevent falls for one resident who sustained 3 falls within 5 weeks. The resident had a history of metabolic encephalopathy, essential hypertension, muscle weakness, and idiopathic peripheral neuropathy, and the Quarterly MDS documented a BIMS score of 8, indicating moderate cognitive impairment. The resident also required maximum assistance with toileting and was dependent on staff for showering and lower-body dressing. The care plan identified the resident as a fall risk due to poor safety awareness, impaired cognition, need for assistance with transfers and mobility, musculoskeletal symptoms affecting balance or strength, and wheelchair use with staff assistance. Interventions included observing for safety, placing the resident in a visible area, making frequent checks, keeping items within reach, and monitoring for changes in cognition or mobility. The record also showed that fall risk assessments rated the resident at low risk, with scores of 17, 13, and 15, and did not include diagnoses such as metabolic encephalopathy, muscle weakness, or idiopathic peripheral neuropathy. The DON confirmed the resident fell 3 times while most alert in the afternoon and evening, and stated the resident would use the wheelchair to propel toward the common area and sometimes slide out of the wheelchair to gain attention. During record review, the DON confirmed the documentation for one fall lacked details of the date, time, circumstances, assessment, and interventions taken at the time of the fall. The DON also stated recent staff turnover affected the resident because new staff needed further orientation to pay close attention to prevent sliding from the wheelchair, and that on the last fall the new CNA did not know the resident well enough to properly supervise.
Failure to Follow Feeding Tube Orders and Weekly Weight Monitoring
Penalty
Summary
The facility failed to follow the physician’s order for a resident with chronic dysphagia who received nutrition via a feeding tube. The record showed an order dated 11/04/25 directing staff to administer 200 ml of water through the feeding tube at 6:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. During observation on 02/04/26 at 11:55 AM, Staff F, RN, flushed the feeding tube with 60 ml of water. In a side-by-side review of the record and interview, Staff F confirmed that 60 ml was used and acknowledged that the ordered 200 ml was not administered. The facility also failed to obtain weekly weights as ordered for the same resident. A physician’s order dated 01/09/26 directed staff to obtain weekly weights every Monday for 4 weeks. Review of the documented weights showed entries on 01/21/26, 01/12/26, 01/05/26, and 12/05/25, but the record lacked documented weights on 01/26/26 and 02/02/26 as ordered. During interview, the DON stated that all staff were responsible for weight checks and that the RN documented them in the electronic chart, and acknowledged there was a coordination issue between Nursing and Dietary. After reviewing the record, the DON agreed the facility did not carry out the order to obtain weekly weights for 4 weeks.
Failure to Provide Ordered Food Preferences and Portions
Penalty
Summary
The facility failed to provide foods according to resident preferences for two sampled residents. Resident #16 was admitted with a quarterly MDS showing the resident was rarely or never understood and was totally dependent on staff for eating. The care plan documented increased nutritional risk related to a mechanically altered diet and the need for assistance with all meals, with an intervention to provide the diet as ordered. However, observation of the resident being fed in the dining room showed a divided plate with pureed meat and pureed carrots, and the third section of the plate was empty. The resident’s menu ticket listed chocolate ice cream daily and mashed potatoes daily, but mashed potatoes were not on the plate, and a tray line observation confirmed there were no mashed potatoes available. A later lunch observation showed the resident did not receive chocolate ice cream, and the CNA confirmed it had not been served. Resident #2 had an annual MDS documenting a BIMS score of 13 and set-up assistance for eating. The resident’s menu ticket indicated a mechanical soft diet with a double portion of protein. During one meal observation, the resident was served a roast beef sandwich with the same amount of roast beef as the other sandwiches at the table. On another meal observation, the resident received only a scoop of ground meat. The resident stated that they did not need double meat that day because they did not feel well, but would take it when feeling better. When a cook was asked to provide a double portion of ground meat, the cook stated, "Oh did I mess up?" and then provided a portion that was more than what had been served to the resident.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations made during a survey. In three resident rooms, the carpets were found to be dirty and stained, and in one room, a bedside table was missing a bolt. Specifically, the survey team noted multiple stains on the carpets in three rooms, and a large bolt was missing from a bedside table in one of these rooms. The Housekeeping Supervisor mentioned plans to replace the carpet, indicating that the Executive Director had received quotes for the replacement. However, the Executive Director later stated that no quotes had been obtained, although he confirmed the ability to replace individual carpet squares. The Executive Director acknowledged the issues with the carpets and the missing bolt during a tour with the survey team.
Inaccurate MDS Assessment for Medication Usage
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, specifically regarding medication usage. The resident was admitted to the facility and the current MDS assessment documented that the resident was taking an antidepressant medication during a specified seven-day look-back period. However, a review of the Medication Administration Record (MAR) for the same period showed no provision of an antidepressant. Instead, the MAR indicated that the resident received an antiplatelet medication, Clopidogrel, and an antianxiety medication, Buspirone, which were not documented in the MDS. During an interview and record review, the MDS Coordinator acknowledged the inaccuracy of the MDS.
Deficiency in Resident Shower and Nail Care
Penalty
Summary
The facility failed to provide showers according to the resident schedule and choice for three residents and timely nail care for one resident. Resident #122, who was admitted with multiple diagnoses including metabolic encephalopathy and congestive heart failure, reported not having received a shower since admission. Observations noted her hair was oily, nails were ragged with a brown substance underneath, and she had an unpleasant body odor. Despite being scheduled for showers twice a week, records showed she only received one bed bath since her re-admission. The Director of Nursing confirmed the lack of showers and attributed it to staffing issues, as Resident #122 required assistance from two aides. Resident #14, with moderate cognitive impairment, expressed uncertainty about the availability of showers at the facility and had not been offered one. He had only received one shower in the past 30 days, with the rest being bed baths. The facility's documentation system for showers was found to be ineffective, as there was no record of showers being provided or refused on several scheduled days. The Director of Nursing acknowledged the inadequacy of the current documentation system. Resident #72, a new admission, had not received a bath or shower within her first few days at the facility, despite being scheduled for showers twice a week. The shower binder and electronic records lacked documentation of any showers or refusals. The Director of Nursing agreed with the concerns raised during the survey, indicating a systemic issue with the provision and documentation of showers for residents.
Pharmacist Fails to Identify Lack of Behavior Monitoring
Penalty
Summary
The consultant pharmacist failed to identify the lack of behavior monitoring for a resident who was on multiple medications, including Buspirone, Haloperidol, and Ativan. The resident had been on Buspirone since February 16, 2024, and Haloperidol since February 5, 2024, with Ativan added to the regimen on July 28, 2024. Despite the requirement for behavior monitoring for these medications, the resident's record lacked any such documentation. Monthly pharmacy recommendations from February to July 2024 did not address this issue. During a phone interview on August 14, 2024, the consultant pharmacist was informed of the concern but did not provide any additional information or recommendations to the Director of Nursing by the time of the exit conference.
Medication Monitoring and Antibiotic Use Deficiencies
Penalty
Summary
The facility failed to adequately monitor medications for two residents, leading to deficiencies in care. For one resident with a diagnosis of Schizophrenia, the facility did not document behavior monitoring for the use of psychotropic medications, including Haloperidol, Buspirone, and Ativan. Despite the care plan indicating the resident exhibited anxious and restless behavior, the monthly Medication Administration Records (MARs) and progress notes from February to August lacked any documented behavior monitoring. Interviews with the Director of Nursing and the MDS Coordinator revealed that the behavior monitoring order might have been omitted during a readmission, and the oversight went unnoticed. In another case, a resident with an indwelling urinary catheter was prescribed the antibiotic Cipro, despite laboratory results indicating resistance to the organism causing the urinary tract infection. The resident received 22 extra doses of Cipro after the culture results were reported, showing the antibiotic was ineffective. The facility's Administrator, who is also a Registered Nurse, acknowledged that the culture results were not reviewed, leading to the continued administration of an inappropriate antibiotic.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to deficiencies in meeting physician-ordered tests. Resident #9 was admitted to the facility and had orders for a CBC and CMP to be drawn on a specified date. However, the records lacked any results for these tests. During an interview, the Director of Nursing (DON) was unable to locate the results or requisition pages for the tests, indicating that the labs were not drawn as ordered. This oversight was discovered when the DON checked the laboratory's website and the laboratory service binder, finding no evidence of the tests being conducted for Resident #9. Similarly, Resident #72 had orders for a urinalysis with culture and sensitivity, as well as a CBC and CMP, but the electronic records did not contain results for these tests. The DON mentioned issues with results not integrating into the electronic record, requiring manual scanning. Upon investigation, the DON found that the CBC and CMP were completed three days late, but no results for the urinalysis were found. The RN involved could not provide a reason for the missing urinalysis, suggesting possible issues with sample labeling or timing. These lapses in laboratory services highlight the facility's failure to adhere to physician orders and ensure timely testing for residents.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter, leading to a deficiency in infection prevention and control. The resident, who was admitted with multiple diagnoses including a urinary tract infection and had a moderately impaired mental status, was observed without an EBP sign on the door and no gowns available for staff use. Interviews with staff revealed a lack of awareness and understanding of the EBP policy, with some staff members incorrectly associating the use of gowns with the completion of antibiotic treatment for ESBL, despite no evidence of ESBL in the resident's urine. The Director of Nursing confirmed that the last staff update on EBP precautions occurred before the implementation of a new policy, and no in-services were conducted to educate staff on the updated procedures. This lack of training and communication resulted in inconsistent application of EBP, as evidenced by staff confusion and the absence of necessary precautions for the resident with a urinary catheter. The deficiency highlights a gap in staff education and policy implementation regarding infection control measures.
Inaccurate and Outdated Menu Posting
Penalty
Summary
The facility failed to ensure that an accurate and current menu was posted for residents who eat their meals at the facility. On a Sunday morning, the daily menu displayed at the entrance to the dining room was incorrectly labeled as the menu for Monday. The menu listed Cracker Crumb Cod, Potato Wedges, Broccoli, Roll, and Brownie as the lunch meal, with an alternate option of Chili with Beans and Baked Potato. However, during the lunch meal observation, residents were served Turkey Shepherd's Pie, Dinner Roll, and Cheesecake, with the only other available meal being a grilled cheese sandwich, tomato soup, and fresh fruit. Additionally, the weekly menu posted on the bulletin board in the dining room was for Week 1, covering dates from August 20 to August 26, which did not include the current week. A resident's significant other expressed confusion over the posted menus, noting that the daily menu had not been updated since the previous Monday. The Certified Dietary Manager, upon returning from vacation, acknowledged that the daily menus were not updated in her absence and corrected the menu on her first day back. She also noted that the weekly menu should have indicated Week 5 instead of Week 1.
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Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Vero Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sea Breeze Rehab And Nursing Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Vero Beach Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Palm Garden Of Vero Beach | 0.8 mi | ★★★★★ | 3 | 0 |
| Garden View Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At Indian River Estates | 5.8 mi | ★★★★★ | 0 | 0 |
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