Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Park Meadows Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Inaccurate MDS assessments were completed for multiple residents. One resident was incorrectly coded as receiving diuretics when records showed hydralazine only, another was coded as not needing an interpreter despite being Spanish-speaking, a resident with a tracheostomy was coded as not receiving trach care, and another resident was incorrectly listed with septicemia despite records showing only a prior short course of Cipro for UTI and no supporting evidence of ongoing infection.
Surveyors found that staff did not consistently follow physician orders for several residents, including an RN repeatedly holding ordered insulin without required physician notification, and an LPN crushing and administering a delayed-release medication without clarifying its appropriateness. Wound care orders for daily and three-times-weekly dressing changes were not carried out as prescribed, with dressings left unchanged for days and staff unable to account for missed treatments. A resident ordered to wear an AFO during transfers and when out of bed was frequently observed without it, while documentation of application was incomplete and CNAs reported not consistently applying or keeping the device on. Another resident on G-tube feeding had feeding and water setups used beyond the ordered timeframe, and an LPN restarted tube feedings and administered medications without checking gastric residuals as required by the physician order.
The facility failed to maintain accurate, resident-centered comprehensive care plans aligned with current assessments and communication needs. One resident with a nephrostomy was incorrectly care planned for a colostomy, while another resident continued to be care planned as a smoker despite no longer smoking or leaving bed to smoke. A third resident, assessed as mostly independent and able to perform personal hygiene such as shaving, still had a care plan stating dependence for all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required interpreter services had no communication focus in the care plan, even though staff and clinical documentation acknowledged the language barrier and use of translation methods.
A resident with hemiplegia had a bed light pull string that was not within reach, and the Administrator acknowledged it was not close enough to accommodate the resident's needs. In another room, staff observed a black substance around the toilet base, and the ESD verified it was present; a CNA stated housekeeping cleans twice daily but that men in the room urinate on the floor.
PASRR screening was not properly coordinated for two residents with behavioral health needs. One resident’s PASRR listed anxiety and depression but omitted later-documented brief psychotic disorder and PTSD, while another resident’s PASRR showed no mental illness despite later diagnoses of mood disorder and major depressive disorder. Psychiatry notes and med orders reflected ongoing depression, insomnia, and psychosis-related treatment, and the DON acknowledged the missing PASRR diagnoses.
A facility failed to keep care plans aligned with residents’ actual needs and status. One resident had an ostomy focus despite having a nephrostomy, another was still listed as a smoker even though she no longer smoked, a third had ADL assistance needs documented despite being mostly independent, and a Spanish-speaking resident had no communication focus even though staff and records noted she needed translation. The DON and MDS LPN acknowledged the mismatches and missing focus areas.
A resident with diabetes had insulin repeatedly held despite orders to give it daily unless blood sugar was below the notification threshold, and an RN stated she misread the order and did not recall notifying the physician. Another resident received a delayed-release dementia medication that an LPN crushed before administration without first obtaining clarification. Two residents also had ordered wound care missed, with dressings left in place beyond the ordered schedule for a biopsy site on the neck and a knee wound, while staff gave inconsistent explanations for the missed care.
Failure to apply an ordered AFO for a resident with limited mobility. The resident had an order to wear a right ankle orthosis during transfers and when OOB to improve positioning, but was observed multiple times without the AFO while in a wheelchair or in bed, and the device was later found stored in the closet. Staff gave inconsistent accounts of when the brace should be worn, and restorative documentation was incomplete.
A resident’s disposable razor was observed left on the bathroom sink on two occasions, including in a shared bathroom accessible to others. Staff described the resident as mostly independent and able to shave himself, but the resident stated he had to get a razor from CNAs and that staff did not always observe him while shaving or remove the razor afterward. Facility policy stated razors must be discarded in the sharps container when no longer needed.
Enteral feeding care was not properly provided for a resident with a G-tube. An LPN started the pump without checking residuals before feeding or meds, and the feeding bottle and water bag were observed dated several days apart. The DON stated tube feeding set-ups and water flush tubing should be changed daily, and the facility policy required residual checks and regular replacement of infusion sets.
Failure to act on pharmacist MRR recommendations affected two residents. One resident had recommendations related to quetiapine without an allowable diagnosis and duplicate antidepressant therapy involving paroxetine and trazodone, while another had recommendations related to Keppra monitoring and duplicate antidepressant therapy involving sertraline and trazodone. In both cases, there was no provider response or signature. Staff stated recommendations were reviewed in bulk, passed to MDs by the DON, and returned signatures were inconsistent.
Unnecessary Medication Administration Outside Ordered Parameters: Two residents received medications outside ordered parameters. One resident was given metoprolol despite BP readings below or near the hold limits, and an LPN stated it was administered in error. Another resident received topical diclofenac as ordered on the MAR until the order was discontinued, with an LPN stating she applied the gel but could not recall the amount. The DON stated staff were expected to clarify unclear medication orders and follow physician parameters, and the MD said he reviewed the residents and found no adverse events.
Medication Storage and Bedside Access Failures: Multiple residents had meds or ointments left at the bedside, including nebulizer treatments, zinc oxide, vitamin A and D ointment, a clear gel ointment, and TUMS, despite staff stating the residents should not have meds at bedside. In the memory care unit, an unattended med cart had a Coreg blister pack with a tablet still present, and the DON policy required meds and biologicals to be kept secure and locked when not in use.
A facility failed to obtain ordered UA C&S testing for two residents. One resident with AMS, a fall, dysuria, urinary frequency, and recurrent MDR UTIs had urine collected but it was not logged or sent to the lab, and no result was found. Another resident had a UA C&S ordered for increased confusion, but the lab record showed no UA completed and staff could not confirm the specimen was collected or processed.
Inaccurate wound care documentation was found for two residents with skin wounds. One resident had a neck biopsy site with a dressing that remained dated and staff gave conflicting accounts about whether ordered daily care was actually completed, while another resident had a right knee wound with a dated dressing and a TAR that did not match the ordered 3x/week treatment. The DON stated documentation should not be checked off unless the wound care is actually done.
An LPN entered a resident’s contact isolation room without gown or gloves despite posted PPE requirements and available PPE. In separate observations, staff failed to perform hand hygiene during medication preparation and wound/nephrostomy dressing care after contamination events and after removing soiled gloves. Respiratory equipment for two residents was also observed improperly maintained, with oxygen tubing left on the floor or bed rail and tubing dates not current.
A resident with orders for multiple medications, including probiotics, vitamin C, Eliquis, Famotidine, and insulin (Glargine and Apidra), had several scheduled doses in one month with no corresponding entries on the MAR. Because the resident disliked certain LPNs, nurses informally split responsibilities so that one nurse administered medications while another documented them, leading to missed documentation when the documenting LPNs forgot or were distracted. This practice conflicted with facility policy requiring the staff providing care to record medications administered, resulting in incomplete and inaccurate clinical records for the resident.
The facility was found to have an unsanitary environment across all hallways, with trash and debris present and no housekeeping staff observed during the inspection. Residents expressed dissatisfaction with the housekeeping services, and the Administrator confirmed the lack of adherence to the cleaning schedule.
A resident with a mechanical soft diet order was served a hotdog, which did not meet dietary restrictions, leading to a finding of neglect. Despite being informed by an RN, the LPN did not remove the food item, and a CNA cut the hotdog for the resident. The resident had a complex medical history, including dysphagia, increasing the risk of aspiration. Staff interviews revealed a lack of adherence to diet verification procedures, contributing to the incident.
A resident with a mechanical soft diet order was inappropriately served a hotdog, despite staff being aware of the dietary restriction. The LPN retrieved the hotdog without verifying the resident's diet, and neither the LPN nor the RN removed the food after realizing the error. The CNA cut the hotdog, but it still did not meet the mechanical soft diet requirements. This led to Immediate Jeopardy due to the facility's failure to provide a safe environment and adequate supervision.
A resident with a mechanical soft diet was improperly served a hotdog, despite staff being aware of the dietary restriction. The LPN failed to verify the diet, and the RN did not remove the food after identifying the error. The resident's complex medical history, including dysphagia, increased the risk of harm, leading to a determination of Immediate Jeopardy.
A resident with specific dietary needs was given a hotdog by an LPN without verifying the diet order, despite an RN's warning. The resident's diet required a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture. The staff failed to remove the inappropriate food item, leading to a determination of neglectful behavior and Immediate Jeopardy due to the facility's failure to implement policies and procedures for therapeutic diets.
The facility failed to serve food at an appetizing temperature, as evidenced by resident complaints and a test tray observation. Residents reported receiving cold food, and a test tray showed food temperatures below the optimal level. The facility's policy requires food to be served at a safe and appetizing temperature, which was not adhered to, resulting in the deficiency.
The facility failed to maintain a clean and secure environment in two shower rooms and the memory care unit. A resident reported mold in the shower rooms, which was confirmed by observations of black substances on the ceilings. In the memory care unit, a door had a gap due to a plywood repair, exposing the interior to the outside. The Maintenance Director was unaware of these issues, despite a policy for maintenance work orders.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as only one fall mat was placed instead of the required two. Additionally, another resident's care plan lacked focus on incontinence care, despite documented needs and staff observations. These deficiencies were contrary to the facility's policy on comprehensive assessments and care plans.
A resident did not receive blood pressure medication according to the physician's order, which specified holding the medication if the SBP was greater than 110. The medication was administered multiple times when the SBP exceeded this parameter. Interviews with the DON and Medical Director confirmed the error, but no negative impact on the resident's health was observed.
Two residents in an LTC facility did not receive dietary services as prescribed by their physicians. One resident, with Alzheimer's and other health issues, was not given the required frozen nutritional treat with meals, despite a physician's order. Another resident, with diabetes and renal disease, received insufficient meal portions, contrary to the prescribed double protein diet. Both cases highlight a failure to adhere to the facility's dietary policies, as confirmed by registered dietitians.
A facility failed to provide timely laboratory services for a resident, missing scheduled tests for Hemoglobin A1c and Depakote levels as ordered by the physician. The oversight was confirmed by the DON, who noted that the tests were conducted only after the issue was identified. The facility's policy requires timely diagnostic services, which was not followed in this instance.
A facility failed to accurately document the provision of a frozen nutritional treat for a resident with a physician's order due to weight loss. Observations showed the resident did not receive the treat during meals, despite the MAR indicating otherwise. Interviews with the DON and an LPN revealed expectations for accurate documentation and meal checks, yet discrepancies were noted.
The facility failed to ensure proper infection control practices, as observed in the actions of a CNA and an LPN who did not sanitize equipment or perform hand hygiene during medication administration. Additionally, a clean linen cart was improperly used to store personal items, violating the facility's infection control policies.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure MDS assessments were accurate for multiple residents. For one resident, the quarterly MDS incorrectly indicated use of diuretics in Section N even though physician orders and the MAR showed no diuretic order or administration; the resident was actually receiving hydralazine for hypertension, and both the DON and MDS LPN confirmed hydralazine is not a diuretic. For another resident, the MDS coded that an interpreter was not needed for communication with staff, even though the resident stated she did not speak English and needed an interpreter, and multiple staff members described her as Spanish-speaking and needing translation assistance. The facility also completed inaccurate MDS coding for a resident with a tracheostomy by indicating no tracheostomy care under Section O despite the resident’s diagnosis of tracheostomy status and an active order to change the trach every 3 months. In addition, another resident’s quarterly MDS listed septicemia under active diagnoses even though the only antibiotic order reviewed was a 7-day course of Cipro for UTI months earlier, subsequent urine studies showed no growth, and no additional antibiotic orders were documented. The DON stated she was aware there was a lot wrong with residents’ MDS assessments and that there had been significant staff turnover in the MDS office.
Failure to Follow Physician Orders for Medications, Wound Care, Orthotic Use, and Enteral Feeding
Penalty
Summary
The deficiency involves multiple failures by nursing and therapy staff to follow physician orders for medications, treatments, devices, and enteral nutrition. One resident with diabetes had an order for daily Insulin Glargine with instructions to notify the physician if blood sugar was less than 70 mg/dL. Review of the MAR showed that an RN repeatedly held the insulin on numerous dates when blood sugars were between 60 and 117 mg/dL, including several instances where no blood sugar was documented at all, and the RN stated she misread the order and did not recall notifying the physician. Another resident had an order for a delayed-release oral medication, Zunveyl 10 mg twice daily, with a general order allowing medications to be crushed unless contraindicated. An LPN crushed the delayed-release tablet and administered it without first clarifying with the provider or pharmacy, later acknowledging that the medication was delayed release and that she should have obtained clarification. The deficiency also includes failures to follow wound care orders for residents with skin conditions. One resident who had a dermatology biopsy on the left side of the neck had a physician order for daily wound care on the day shift for seven days, including washing with soap and water, applying petroleum jelly, and covering with a nonstick bandage. Observations on two consecutive days showed the same dressing dated several days earlier still in place, and the resident reported that the dressing had not been changed. Nursing staff interviewed either did not recall the dressing date, stated they did not see dressing change orders, or could not recall what happened on the ordered wound care day. Another resident with a right knee wound from a fall at home had an order for wound care three times weekly on the day shift (Tuesday, Thursday, Saturday). The wound care nurse stated she worked on the relevant Saturday but did not perform the ordered dressing change because the resident was up, and the DON stated staff should follow physician orders and perform wound care as ordered. Additional deficiencies occurred in the implementation of therapy-related and enteral feeding orders. One resident with an order for a right ankle orthosis (AFO) to be applied during transfers and when out of bed was repeatedly observed in a wheelchair and in bed without the AFO, while the device was stored in the closet. The task list showed documentation of AFO application for several days early in the month but no entries on later dates when the resident was observed without the device. Therapy and nursing staff described that restorative aides were to apply the AFO, but a restorative CNA reported they were not applying it and were instead working with a hand splint, and a CNA stated she sometimes removed the AFO when the resident was sitting because she thought he did not like to wear it. Another resident receiving enteral nutrition via G-tube had a physician order for Jevity 1.5 at a specified rate and schedule, with an order to check tube residual prior to feeding, medications, and flushes, and to hold feeding and notify the physician if residual was 100 mL or more. Observations showed the feeding bottle and attached water bag in use beyond 24 hours, and an LPN stated she believed the setup was good for 24 hours and based changes on what was left in the bottle. When restarting the feeding, the LPN set the pump according to the order but did not check for residual, and she confirmed she did not check residuals prior to medication administration or initiation of feeding, despite the physician order and facility policy requiring verification of tube placement and residual volumes.
Failure to Maintain Accurate, Resident-Centered Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain accurate, resident-centered comprehensive care plans consistent with residents’ assessed needs and conditions. For one resident with hemiplegia, overactive bladder, and a nephrostomy catheter, the care plan incorrectly documented a focus on an artificial bowel opening (ostomy/colostomy) with related bowel-output interventions, even though the resident did not have a colostomy. The MDS LPN and the DON both confirmed that the resident had a nephrostomy, not a colostomy, indicating the care plan did not reflect the resident’s actual medical status. Another resident with pulmonary fibrosis, morbid obesity, malnutrition, feeding difficulties, malignant neoplasm of the glottis, dysphagia, and GERD had a care plan focus indicating the resident was a smoker/tobacco user, initiated and last revised several years earlier. Interviews with the resident, an LPN, and the DON confirmed that the resident no longer smoked, did not get out of bed or go outside to smoke, and had not had a recent smoking evaluation because the resident was no longer an active smoker. Despite this, the care plan still identified the resident as a smoker, showing it had not been updated to reflect the resident’s current status. A third resident with hemiplegia, seizures, dementia with behavioral disturbance, and restlessness/agitation had a care plan focus stating the resident had self-care deficits and required assistance with all ADLs, including dressing, grooming, and bathing. However, interviews with nursing staff and the resident indicated the resident was mostly independent, steady, moved independently, and shaved independently after obtaining a razor from CNAs. The MDS assessment completed the prior month documented the resident as independent for personal hygiene, but the care plan, last updated many months earlier, still showed a need for assistance with all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required an interpreter had no communication focus in the care plan, despite documentation in a skin exam note that a translator app and the resident’s son were used for communication, and staff interviews confirming the resident primarily spoke Spanish. The MDS LPN and DON acknowledged that care plans were not up to date and that a communication focus needed to be added, demonstrating that the care plans did not incorporate identified communication needs or align with the facility’s policy requiring culturally competent care planning.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for two residents. Resident #87, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, was observed with his right arm in a splint and using his left arm and hand to move items in his room. The pull string for the light over his bed was not within reach, and the resident stated he had concerns about not being able to reach it and had spoken to maintenance and administration. The pull string was observed again on later dates and remained out of reach of the resident. The Administrator acknowledged that the light string was not close enough to the resident's bed to accommodate his needs and needed to be made longer. Resident #66 was observed with a black colored substance around the base of the toilet in the room bathroom. The Environmental Services Director verified the substance was present around the toilet base. The ESD stated the memory care unit rooms were cleaned twice a day, once in the morning and once in the afternoon. A CNA also stated housekeeping cleans twice a day and noted that the bathroom was nice when clean, but that the men in the room urinate on the floor.
PASRR Screening Not Coordinated for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate PASRR for 2 of 4 residents reviewed for behavioral health, involving residents with newly evident or possible serious mental disorder. Resident #117’s record showed admission and readmission with diagnoses including brief psychotic disorder, other recurrent depressive disorders, and PTSD, while the PASRR dated 1/27/2026 documented anxiety disorder and depressive disorder under mental illness or suspected mental illness but did not include brief psychotic disorder or PTSD. Subsequent psychiatry documentation identified brief psychosis and depression, and physician orders later included escitalopram for depression and aripiprazole for brief psychotic disorder. Resident #13’s admission record showed diagnoses including unspecified mood disorder and major depressive disorder, recurrent, but the PASRR dated 3/8/2026 documented no mental illness or suspected mental illness in Section I. A psychiatry note later listed depression and insomnia, with a plan to start trazodone for daytime anxiety/depressive symptoms and insomnia/depressive symptoms. During interview, the DON stated that both residents were missing diagnoses on their PASRR Level I and needed to be corrected. The facility policy stated that residents must be screened for mental disorder or intellectual disability prior to admission and that individuals with mental disorder or intellectual disabilities must be evaluated and receive care and services in the most appropriate setting when a significant change in status occurs.
Care Plans Did Not Match Resident Needs or Current Status
Penalty
Summary
The facility failed to ensure resident-centered care plans were developed and implemented for 4 of 33 residents reviewed. For Resident #11, the care plan focused on an artificial opening for bowel elimination (ostomy), with interventions to report changes in bowel output, swollen abdomen, pain, or changes in color or consistency of output. However, staff stated the resident had a nephrostomy catheter, not a colostomy, and the DON confirmed the resident did not have a colostomy. For Resident #58, the care plan identified the resident as a smoker/tobacco user with a focus initiated in 2016 and revised in 2023. The resident stated she used to smoke but no longer did, and staff stated she did not get out of bed or go outside to smoke. The DON confirmed the resident had not had a recent smoking evaluation because she was no longer an active smoker. For Resident #39, the care plan stated the resident had self-care deficits and needed assistance with dressing, grooming, and bathing related to CVA with right hemiparesis/hemiplegia. Staff interviews and the resident’s statements indicated he was mostly independent, moved on his own, shaved himself, and his most recent MDS assessment showed him independent for personal hygiene. For Resident #112, the resident stated she did not speak English and needed an interpreter, the skin exam documented that she did not speak English and translation was used, and staff confirmed she preferred Spanish; however, the care plan did not include a communication focus. The DON and MDS LPN acknowledged the communication focus was missing.
Medication Administration and Wound Care Not Performed as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. For one resident with diabetes, the physician ordered Insulin Glargine 10 units subcutaneously once daily and to notify the physician for blood sugar less than 70 mg/dL, but the MAR showed the insulin was repeatedly held on multiple dates in March and April 2026 for blood sugars that were above the ordered notification threshold, and on some dates there was no blood sugar documented. The RN stated she misread the physician order, held the insulin, and did not recall notifying the physician. The DON stated nursing staff were expected to follow physician orders, and the physician stated he did not recall being notified that the insulin was being held. For another resident, Staff A, LPN, was observed crushing Zunveyl Oral Tablet Delayed Release 10 mg before administration. When asked to clarify whether the medication should be crushed, Staff A stated she would get clarification from the provider but administered the medication without obtaining it. The resident had an order for Zunveyl 10 mg by mouth twice daily for dementia, and another order stated medications could be crushed unless contraindicated. The DON stated delayed release medication should not be crushed and that staff should first call pharmacy or the doctor for clarification before giving the medication. The facility also failed to carry out ordered wound care for two residents. One resident had a biopsy site on the left neck with a dressing dated 4/16/2026 that remained in place during observations on 4/20 and 4/21, despite an order for daily wound care to wash, apply petroleum jelly, and cover with a nonstick bandage for 7 days. Staff gave inconsistent statements about the dressing change and wound orders. Another resident had a right knee wound with a dressing dated 4/16 that was still present on 4/20, although the order required cleansing, Iodosorb gel, and border gauze three times weekly on Tuesday, Thursday, and Saturday. The wound care nurse stated he did not do the dressing on Saturday because the resident was up, and the DON stated staff should follow physician orders and do wound care as ordered.
Failure to Apply Ordered AFO for Resident With Limited Mobility
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate services to maintain or improve mobility. Resident #16 had an order dated 1/28/2026 to apply an orthosis to the right ankle following the restorative nursing program, and that order was discontinued on 4/2/2026. A new order dated 4/2/2026 directed staff to apply the right ankle orthosis (AFO) during transfers and when out of bed to improve positioning and to monitor skin integrity. During multiple observations, the resident was seen sitting in a wheelchair next to the bed, sitting at the nurses' station, and lying in bed without the AFO on, and the AFO was later found stored on a shelf in the closet. Staff interviews showed inconsistent application of the AFO. An LPN stated the resident was often up in the wheelchair and not always wearing the AFO, while the Director of Rehab stated the AFO was to be applied when the resident got up with the mechanical sit-to-stand and remain on to stabilize the foot and lower leg position. The Unit Manager stated therapy had given recommendations to restorative aides and that training was provided for new splinting tasks. The restorative task list showed documentation only from 4/2/2026 through 4/8/2026 and no entry on 4/20/2026 or 4/22/2026. A restorative CNA stated restorative was not applying the AFO and was instead working with the resident on a right hand device, while another CNA stated she knew the AFO was supposed to be on during transfers but sometimes removed it when the resident was sitting in the wheelchair because she thought he did not like to wear it.
Disposable razor left accessible in resident bathroom
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for one resident when a disposable razor was observed in the resident’s bathroom on two separate occasions. During observation, the razor was found on the back of the bathroom sink and later on the sink in the resident’s bathroom. The resident’s bathroom was shared with a roommate, and other residents had access to the bathroom. The resident stated that he did not shave that day, did not have a razor in his room, had to obtain a razor from CNAs, and that staff did not observe him while shaving or always pick up the razor after use. Staff interviews showed that the resident was described as mostly independent, steady, and able to shave himself. A CNA stated the resident had been using the razor earlier that day, while an LPN and the unit manager stated that residents should be observed while shaving and the razor should be disposed of after use. The DON also stated the resident should be observed while shaving and that the CNA would have known he was shaving because she would have had to give him the razor and should have picked it up after he was finished. The facility policy stated that disposable items are to be discarded when no longer needed and that razors must be discarded in the sharps container.
Enteral Feeding Setup and Residual Checks Not Performed
Penalty
Summary
The facility failed to ensure appropriate enteral feeding for Resident #58, who had a physician order for Jevity 1.5 at 50 cc/hour via feeding tube for 20 hours with autoflush and a separate order to check tube residuals prior to feeding, medication administration, and flushes. During an observation, the resident was lying in bed while the tube feeding pump was alarming, and the bottle of enteral feeding was dated 4/18/2026 while the attached water bag was dated 4/15/2026. The resident also had an order allowing the feeding tube/pump to be off for short periods for ADL care, activities, or appointments. During a later observation, an LPN attached the enteral feeding tubing, set the pump according to the order, and started the pump without checking residual prior to initiating the feeding. The LPN stated she did not check residual for the resident's G-tube prior to medication administration or prior to starting the enteral feeding. The DON stated that tube feeding set-ups and water flush tubing should be changed every day and that the nurse was expected to confirm placement of the feeding tube, including checking for residual. The facility policy also stated that infusion sets should be replaced every 24 hours for open tube systems or 48 hours for closed tube feed systems, or per manufacturer's guidelines.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure provider action on pharmacist recommendations for 2 of 5 residents reviewed. For Resident #66, the consultant pharmacist recommended physician review of quetiapine because the resident lacked an allowable diagnosis to support its use, and later identified duplicate antidepressant therapy involving paroxetine and trazodone; neither recommendation had a provider response or signature. For Resident #67, the consultant pharmacist recommended physician review of a Keppra serum level interpretation, and later identified duplicate antidepressant therapy involving sertraline and trazodone; neither recommendation had a provider response or signature. During interviews, the Nursing Consultant stated that the pharmacy monthly consultations were all that was available. The Medical Doctor stated that he had gotten delayed and received recommendations in bulk, saying it was more on him than the pharmacy. The DON stated that she reviewed the recommendations and gave them to each doctor by email or in their book, and that the physician signs the recommendations and returns them, but that process was described as a hit or miss. The facility policy stated that it would provide pharmacist services through monthly regimen review and properly address recommendations per federal and state guidelines.
Unnecessary Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs for 2 of 8 residents reviewed. For one resident, a physician order dated 3/29/2026 directed Metoprolol Succinate ER 50 mg twice daily for hypertension, with instructions to hold the medication for SBP less than 110 or DBP less than 60. The April 2026 MAR showed the medication was administered on multiple occasions when the resident’s blood pressure was outside the ordered parameters, including readings of 111/58, 110/54, 93/51, 108/90, and 108/65. During interview, an LPN stated the medication was administered in error. For another resident, a physician order dated 1/31/2026 directed Voltaren Arthritis Pain External Gel 1% to both hands twice daily for pain, and the order was later discontinued on 4/20/2026. The April 2026 MAR showed the gel was applied twice daily on multiple days in April before discontinuation. During interview, an LPN stated she put on gloves and massaged the medication into the resident’s hands but did not remember specifically how much was applied. The DON stated staff were expected to clarify incomplete or unclear medication orders with the provider and follow physician-ordered parameters when administering medications. The physician stated he was aware the two residents had received medications outside of ordered parameters and reviewed them, stating the administrations did not result in any adverse events.
Medication Storage and Bedside Access Failures
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in multiple resident areas and on a medication cart. During observations, two vials of nebulizer treatment and later two clear plastic ampules of nebulizer treatment were found on top of Resident #137's drawer, and Staff W stated the resident should not have medication at bedside. Zinc oxide ointment and packets of vitamin A and D ointment were observed on top of Resident #59's drawer, and the resident stated nurses assist with applying the ointment; Staff W again stated the resident should not have medications at bedside. Resident #151 was observed applying a clear gel-like ointment from a medication cup to his hands, and he stated he used it for dry skin; Staff W stated the resident should not have medication at bedside and said the resident had told her he had his own ointment. Resident #3 was observed with a bottle of TUMS on the bedside table, and Staff X confirmed the resident was not able to self-administer medications and should not have medication at bedside. In the memory care unit, the medication cart was observed unattended with a medication card pack turned upside down on top of the cart and one tablet still present in a sealed blister bubble of Coreg 6.25 mg prescribed to Resident #54 for hypertension. The Assistant DON stated the nurse must have stepped away and that all medications should be secured, while Staff E stated she thought the card was empty and was going to reorder it. The facility policy titled Medication/Biological Storage stated medications, drugs, and biologicals are to be stored in a safe, secure, and orderly manner, and that compartments containing them shall be locked when not in use and carts used to transport them shall not be left unlocked if out of a nurse's view.
Failure to Obtain Ordered UA C&S Testing
Penalty
Summary
The facility failed to obtain ordered laboratory services for two residents when urinalysis with culture and sensitivity was not completed as ordered. For one resident with altered mental status, a fall, possible UTI, dysuria, urinary frequency, and a history of recurrent UTIs with multidrug resistance, the provider ordered a UA C&S and later documented that the test had been ordered earlier in the week but was not sent out. The record showed the urine was collected and placed in the refrigerator, but it was not logged and the lab did not pick it up, and no UA C&S result was found in the record for the dates the test was ordered. For another resident, a physician order was written for UA C&S due to increased confusion, but the laboratory record did not show a UA for that month. Staff interviews showed uncertainty about whether the order was verbal, why it was placed, and whether the urine specimen was collected. The DON stated she could not find documentation that the urine was collected, and the laboratory medical biller reported no UA order for that resident beyond earlier blood work. The facility policy stated it would provide or obtain timely laboratory services when ordered by a physician or other authorized practitioner.
Inaccurate wound care documentation
Penalty
Summary
The facility failed to ensure complete and accurate medical records for 2 residents with skin conditions. For Resident #112, surveyors observed a dressing on the left side of the neck that remained dated 4/16/2026 during observations on 4/20/2026 and 4/21/2026. The resident stated dermatology had seen the area and decided to biopsy the neck, and later stated the dressing had not been changed. The physician order required daily wound care to the left neck biopsy site for 7 days, and the TAR showed wound care documented as completed on 4/17/2026, 4/18/2026, and 4/20/2026. Staff gave conflicting statements about whether the dressing had been changed and why wound care was checked off as completed. For Resident #119, surveyors observed a dressing dated 4/16 on the right knee during an observation on 4/20/2026. The resident stated he had fallen at home and had a wound on his right knee. The physician order required cleansing the right knee and applying Iodosorb gel with border gauze three times weekly on Tuesday, Thursday, and Saturday, but the TAR showed wound care was provided only on 4/18/2026. The wound care nurse stated she did work on 4/18 but did not do the dressing on Saturday, and later said she did not remember what happened. The DON stated staff documentation should be accurate and should not be checked off unless wound care is actually done.
Infection Control Lapses With PPE, Hand Hygiene, and Oxygen Equipment
Penalty
Summary
Staff failed to follow contact precautions for a resident with a physician order for contact isolation due to Candida auris. During an observation, an LPN entered the resident’s room without wearing a gown or gloves even though a contact-precaution sign was posted on the door and PPE was available outside the room. The LPN stated she forgot and went in after seeing the call light. The facility’s infection preventionist and DON stated staff should wear gown and gloves before entering the room, including to answer a call light, and the facility policy required gown use upon entry for contact precautions. Hand hygiene was not performed during medication administration and wound care for multiple residents. While preparing medications for one resident, an LPN dropped a medication package on the floor, picked it up, discarded it, and continued preparing and administering the medication without washing her hands. During wound care for one resident, a wound care LPN removed soiled gauze and gloves, then donned clean gloves and applied a dressing without hand hygiene. During nephrostomy dressing care for another resident, an LPN removed soiled gloves, did not perform hand hygiene, and put on clean gloves to clean the insertion site and again before applying a transparent dressing. The DON stated staff should wash hands after picking anything off the floor before resuming medication preparation and after removing soiled gloves during wound care. Respiratory equipment was also observed not to be maintained as documented for two residents receiving oxygen therapy. One resident’s nasal cannula tubing was observed on the floor and later wrapped on the bed rail, while the tubing remained dated several days earlier. Another resident’s oxygen tubing connected to a trach mask was observed dated several days earlier on multiple observations. Staff stated oxygen tubing should be stored in a respiratory bag when not in use, changed if it falls on the floor, and changed weekly; the DON stated the tubing should be changed weekly and replaced if it falls on the floor. The facility policy stated oxygen tubing should be dated appropriately to show it was changed.
Incomplete Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for one resident related to medication administration. Physician orders for this resident included Acidophilus 100 mg capsules twice daily, Ascorbic Acid 500 mg tablets twice daily, Eliquis 5 mg twice daily for unspecified atrial flutter, Famotidine 20 mg twice daily for GERD, Insulin Glargine 35 units subcutaneously twice daily for diabetes in a dialysis patient, and Apidra SoloStar 8 units subcutaneously before meals for type 2 diabetes with complications. Review of the resident’s MAR for December showed missing documentation entries for multiple scheduled doses of these medications, including Acidophilus, Ascorbic Acid, Eliquis, Famotidine, Insulin Glargine, and Apidra at specified afternoon/evening administration times. Interviews with nursing staff revealed that the resident did not like certain LPNs, leading to an informal practice where one nurse would administer the medications while another nurse was responsible for documenting them on the MAR. One LPN stated she gave all of the resident’s medications on a specific date and expected another LPN to document them, while that LPN acknowledged she was supposed to document the medications but must have forgotten. Another LPN reported that, due to the resident’s verbal abuse, another nurse administered the medications while she pulled the insulin and verified with the other nurse that the medications were given, but she believed she became distracted and failed to sign off on the MAR. The facility’s policy on Charting and Documentation required that medications administered and services performed be recorded in the resident’s clinical record by the staff providing care, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain an orderly and sanitary environment across all four hallways (100, 200, 300, and 400), as observed during a tour on March 29, 2025. Trash and debris were noted in these areas, with no housekeeping carts present during the inspection. Specific observations included significant debris near the exit to the smoking patio on the 100 hallway, consisting of leaves, grass, and small pieces of trash. Interviews with residents revealed dissatisfaction with the housekeeping services, with one resident describing it as a 'joke.' Further observations confirmed the continued presence of trash and debris, and a large, uncovered cart filled with soiled linens and trash was noted, emitting a foul odor. Additionally, a brownish dried liquid was observed on the wall in the 100 hallway. The Administrator confirmed the unsanitary conditions and acknowledged that the housekeeping staff did not work on the morning of the inspection. The Administrator stated that housekeeping personnel are expected to follow a checklist for cleaning rooms and common areas, but this schedule was not adhered to. The absence of housekeeping staff and the failure to follow the cleaning checklist contributed to the unclean environment observed during the survey.
Failure to Adhere to Dietary Restrictions Leads to Neglect
Penalty
Summary
The facility failed to protect a resident from neglect by not adhering to the prescribed dietary requirements. A resident, who had a physician's order for a mechanical soft diet, was served a hotdog and hotdog bun, which did not comply with the dietary restrictions. Despite being informed by a Registered Nurse (RN) that the resident should not have a hotdog, the Licensed Practical Nurse (LPN) did not remove the food item. The resident attempted to consume the hotdog, and a Certified Nursing Assistant (CNA) further facilitated this by cutting the hotdog in half, although this did not meet the mechanical soft diet requirements. The resident involved had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, malnutrition, and dysphagia, which increased the risk of aspiration and choking. The Speech Therapy evaluation indicated the resident was on a mechanical soft diet due to decreased oral function and risk of aspiration. Despite these clear dietary restrictions, the staff failed to verify the resident's diet before serving the hotdog, and the error was not corrected even after it was identified. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding diet verification and neglect prevention. The LPN admitted to freezing and not removing the plate due to the presence of a surveyor, while the RN assumed the LPN would take corrective action. The Cook and Food Service Director acknowledged that the procedure for verifying diet orders was not followed, contributing to the incident. The facility's failure to implement its policies and procedures for neglect led to the determination of Immediate Jeopardy.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Nursing Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Inappropriate Diet Served to Resident with Mechanical Soft Diet Order
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was served an inappropriate therapeutic diet. The incident involved a resident who had a physician's order for a mechanical soft diet due to conditions including dysphagia and risk for aspiration. Despite this, the resident was served a hotdog, which was not suitable for their dietary needs. The error was identified by a registered nurse, but neither the nurse nor the licensed practical nurse who served the meal took action to remove the inappropriate food item. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and other health issues, was observed in the dining room requesting an alternative food item. The licensed practical nurse retrieved a hotdog from the kitchen without verifying the resident's dietary restrictions. Although the registered nurse informed the licensed practical nurse that the resident should not have a hotdog, the food was not removed, and the resident attempted to consume it. A certified nursing assistant later cut the hotdog in half, but this did not meet the requirements of a mechanical soft diet. Interviews with staff revealed a lack of adherence to procedures for verifying and serving appropriate diets. The cook did not verify the resident's diet due to the absence of a meal ticket, and the licensed practical nurse did not follow the protocol of checking the diet before serving the food. The registered nurse, overwhelmed with other tasks, assumed the licensed practical nurse would correct the mistake but did not intervene directly. This series of actions and inactions led to the determination of Immediate Jeopardy, highlighting the facility's failure to provide adequate supervision and a safe environment for the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Dietary Policies Leads to Immediate Jeopardy
Penalty
Summary
The facility administration failed to effectively manage resources to ensure the highest practicable physical well-being of each resident, specifically by not implementing policies and procedures related to neglect and therapeutic diets. A resident with a physician's order for a mechanical soft diet was served a hotdog, which was not in compliance with their dietary needs. Despite being informed by a registered nurse that the resident should not have a hotdog, the licensed practical nurse did not remove the food item, and a certified nursing assistant further facilitated the resident's consumption by cutting the hotdog in half. The resident in question had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, and dysphagia, which increased their risk for aspiration and choking. The resident had been evaluated by a speech therapist and was on a mechanical soft diet due to these risks. However, the staff involved failed to verify the resident's dietary needs before serving the hotdog, and even after recognizing the error, they did not take corrective action to remove the inappropriate food item. Interviews with staff revealed a lack of adherence to established procedures for verifying and serving diets. The licensed practical nurse did not verify the resident's diet with the kitchen staff, and the cook did not follow the procedure of checking the diet ticket or verifying the diet with the nurse. The registered nurse, although aware of the dietary error, did not intervene effectively to prevent the resident from consuming the inappropriate food. This series of actions and inactions led to a determination of Immediate Jeopardy due to the potential harm posed to the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Therapeutic Diet Policies
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a deficiency in implementing policies and procedures for neglect and therapeutic diets. On October 15, 2024, a resident requested an alternative food item from a Licensed Practical Nurse (LPN) in the dining room. The LPN provided a hotdog and hotdog bun without verifying the resident's diet in the kitchen. A Registered Nurse (RN) identified the error, stating that the resident was not supposed to have a hotdog, but neither the RN nor the LPN removed the food item from the resident. The resident, who had a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture and thin consistency, was observed picking up the hotdog and placing it in his mouth, although he did not chew or swallow it. A Certified Nursing Assistant (CNA) then cut the hotdog in half, allowing the resident to attempt to consume it again. The resident's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, and diabetes, which necessitated adherence to a specific diet. The facility's failure to act upon the identified dietary error and remove the inappropriate food item was determined to be neglectful behavior. The incident was classified as Immediate Jeopardy due to the systemic breakdown in implementing the facility's policies and procedures, which was not addressed through the QAPI process. The Nursing Home Administrator acknowledged the failure to act and recognized the neglectful nature of the staff's inaction.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Deficiency in Serving Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as evidenced by multiple resident complaints and a test tray observation. Resident #105 reported that breakfast trays often arrived late, resulting in cold food. Similarly, Resident #109 also complained about receiving cold food. During a test tray observation, food temperatures were measured using a calibrated thermistor digital thermometer. The food, which included ravioli with meat sauce and Italian green beans, was placed on a tray and in an insulated cart at 12:10 PM and left the kitchen at 12:14 PM. By the time the last resident began eating at 12:42 PM, the food temperatures were recorded at 109 degrees Fahrenheit for the ravioli and 89.6 degrees Fahrenheit for the green beans, both below the optimal serving temperature. The Registered Dietitian confirmed that the optimal food temperature when served should be above 110 degrees Fahrenheit, and the kitchen ensures food is above 135 degrees when initially placed on plates. The facility's policy, last reviewed on January 31, 2024, mandates that food and drink be nutritious, palatable, attractive, and served at a safe and appetizing temperature. Despite these guidelines, the facility did not adhere to its policy, resulting in the deficiency noted during the survey.
Facility Fails to Maintain Clean and Secure Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and comfortable environment in two shower rooms and the memory care unit. During an interview, a resident reported that the shower rooms were consistently dirty and moldy. Observations confirmed the presence of a black substance in a circular pattern on the ceiling over the shower area and brown discoloration on the ceiling leading to the shower area in the 100 Hall Shower Room. Additionally, a line of black substance spots was observed on the ceiling over the area leading into the shower in the 500 Hall Shower Room. The Maintenance Director was unaware of these issues. In the memory care unit, a hallway exterior exit door had a large piece of plywood attached where glass should have been, with a 2-inch gap between the plywood and the metal door frame at the bottom, exposing the interior to the outside. During an observation with the Maintenance Director and Housekeeper Supervisors, it was confirmed that the duct tape used to secure the plywood had come off, leaving a gap. The Maintenance Director acknowledged he was unaware of the gap and the tape's failure. The facility's policy on maintenance work orders was reviewed, indicating a system for requesting and completing maintenance, but it appears this system was not effectively implemented in these instances.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as being at risk for falls. Observations on multiple occasions revealed that the resident had only one fall mat placed on the left side of the bed, despite a physician's order and care plan specifying that fall mats should be placed on both sides. This discrepancy was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the expectation to follow physician orders and care plans. Additionally, the facility did not develop a comprehensive care plan for another resident who was occasionally incontinent of bowel and bladder. The resident's care plan lacked a focus on incontinence care, despite the resident's condition being documented in the Minimum Data Set and physician orders for medication related to urinary retention. Interviews with staff indicated that the resident often refused to be cleaned up, yet this issue was not addressed in the care plan, contrary to the facility's policy on comprehensive assessments and care plans.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to administer blood pressure medication as prescribed by the physician for a resident. The physician's order for the resident, dated March 6, 2024, specified that Midodrine HCl Tablet 10 mg should be given every 8 hours for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. However, the Medication Administration Record (MAR) for October 2024 showed that the medication was administered multiple times when the resident's SBP was above the specified parameter, including readings of 116, 122, 126, 124, 114, 127, 125, 123, and 112. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the medication was given outside the prescribed parameters. The DON acknowledged the error but noted that the resident had recently attended a cardiology appointment and was reportedly fine, with no negative impact observed. The Medical Director also reviewed the situation and revised the parameters, stating that the resident's health was stable and monitored, with no adverse effects from the medication administration error.
Failure to Provide Prescribed Dietary Services
Penalty
Summary
The facility failed to provide dietary services as prescribed by the physician for two residents, leading to deficiencies in their nutritional care. Resident #43, who has a history of Alzheimer's dementia, feeding difficulties, and other health issues, was observed multiple times without receiving the prescribed frozen nutritional treat with meals, despite a physician's order for it due to weight loss. The resident's care plan indicated a risk for alteration in nutrition and hydration, yet the prescribed dietary interventions were not consistently followed, as evidenced by the absence of the nutritional treat during meal observations. Resident #128, who has a diagnosis of type 2 diabetes mellitus, end-stage renal disease, and other health conditions, was also not provided with meals that met the prescribed dietary requirements. The resident's physician order specified a renal controlled carbohydrate diet with double meat/protein with meals, but observations revealed insufficient meal portions, such as a half peanut butter and jelly sandwich for lunch, which was deemed inadequate by the registered dietitian. The resident experienced significant weight loss, further indicating that the dietary needs were not being met as prescribed. The facility's policy and procedure for providing diets to meet the needs of each resident were not adhered to, as both residents did not receive meals consistent with their physician's orders. The registered dietitians acknowledged the inadequacy of the meals provided, highlighting a failure in the facility's food and nutrition services to ensure that residents' nutritional and hydration needs were met according to their individual care plans and physician orders.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, specifically for the monitoring of Hemoglobin A1c and Depakote levels, as ordered by the physician. The physician's order, dated June 18, 2024, required these tests to be conducted every three months. However, a review of the resident's medical record revealed no documentation of the laboratory tests being performed in September 2024. During an interview, the Director of Nursing confirmed that the lab work was not completed as scheduled and stated that the blood was drawn on the morning of October 17, 2024, after the oversight was discovered. The facility's policy, last reviewed on January 31, 2024, mandates the provision of timely laboratory, radiology, and diagnostic services when ordered by a physician or other qualified healthcare professionals. This policy was not adhered to in the case of the resident, leading to a deficiency in meeting the resident's healthcare needs.
Failure to Accurately Document Nutritional Supplementation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident identified as having a physician's order for a frozen nutritional treat with meals due to weight loss. Observations over several days revealed that the resident did not receive the frozen nutritional treat during meals, despite the physician's order. Specifically, during meal observations on multiple occasions, the resident was noted to be eating various meals without the prescribed frozen nutritional treat. The Medication Administration Record (MAR) inaccurately documented that the resident received the frozen nutritional treat at specified times, which was contradicted by direct observations. Interviews with the Director of Nursing and a Licensed Practical Nurse highlighted expectations for accurate documentation and meal tray checks, yet discrepancies persisted. The facility's policy on charting and documentation mandates that services provided to residents be accurately recorded, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and the handling of medical equipment and clean linens. During observations, a Certified Nursing Assistant (CNA) did not sanitize a vital sign machine between residents, using it on multiple residents without cleaning. The CNA acknowledged the oversight, stating that disinfecting wipes were not available on their cart at the time. Additionally, a Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after administering medications to residents, even after donning and doffing gloves. The LPN admitted to not using hand sanitizer between residents, which is against the facility's hand hygiene policy. Furthermore, the facility did not maintain a clean storage environment for linens. A clean laundry cart was found with a bottle of coke and a bag of chips among the clean sheets, which was confirmed by the Housekeeping Supervisor as inappropriate. The facility's policy on handling linens to prevent infection was not adhered to, as evidenced by the improper storage of personal items on the clean linen cart.
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 80 citations issued within 25 miles in the last 12 months — including the 3 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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hammock At The University Of Florida Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Gainesville Health And Rehabilitation | 1.5 mi | ★★★★★ | 4 | 0 |
| Plaza Health And Rehab | 1.5 mi | ★★★★★ | 19 | 0 |
| Parklands Care Center And Rehab | 2.6 mi | ★★★★★ | 19 | 0 |
| Palm Garden Of Gainesville | 2.9 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.