Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Meadow View Center during CMS and state inspections, most recent first.
Failure to assess potential restraints in a resident’s bed: staff placed pillows and a blanket under the fitted sheet on both sides of the bed and positioned a geri-chair next to the bed. The resident had schizophrenia, bipolar disorder, epilepsy, dementia, and severe cognitive impairment, and staff described the resident as restless, unpredictable, and a fall risk. The chart lacked an order, restraint/device assessment, or care plan entry for these items, and staff said the setup looked like a restraint and should not have been done.
The facility failed to implement the Wound Physician's treatment recommendations for two residents with pressure ulcers, leading to deficiencies in care. One resident with multiple sclerosis and dementia did not receive the recommended dressings and frequency of changes for a Stage IV pressure wound and an unstageable injury. Another resident with a Stage IV sacral ulcer did not receive the recommended superabsorbent gelling fiber and skin prep. The Wound Physician was not notified of these deviations, and the Director of Nursing acknowledged the failure to address and document the treatment recommendations.
The facility failed to store and handle food according to professional standards, with undated food items and personal drinks stored improperly. Additionally, residents were served undercooked unpasteurized eggs, posing a risk for Salmonella infection. The facility's policies on food labeling and dating were not followed, as confirmed by the Food Service Director.
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as staff did not wear precaution gowns during high-contact activities. Additionally, a nurse did not perform proper hand hygiene during wound care for a resident with a stage four pressure ulcer. Shared equipment was also not sanitized between resident uses, as observed with a vitals machine. These lapses were contrary to facility policies and CDC recommendations.
The facility failed to provide a dignified dining experience for residents in the dementia unit, as observed by surveyors. Residents were often left waiting for their meals while their tablemates were already eating, leading to situations where they asked if meals were theirs or took food from others. The DON noted the unpredictability of residents' seating as a challenge, but the repeated delays in serving meals compromised the residents' dining experience.
A resident with cognitive impairment and severe vision issues did not receive the prescribed dysphagia diet and adaptive equipment during meals, as the care plan was not properly implemented. Staff were unaware of the resident's needs, leading to meals being served on regular plates without supervision.
A resident's care plan was not updated to reflect their current eating needs, leading to inappropriate interventions being listed. The resident, who was cognitively intact and did not receive tube feeding, was observed eating while lying flat due to discomfort from elevating the head of the bed. Despite staff awareness of the resident's condition, the care plan was not revised to remove tube feeding interventions and address the resident's preferences.
A resident with multiple sclerosis and dementia did not receive timely wound treatments as ordered by a Wound Physician. Despite the facility's policy requiring adherence to physician orders, there was a 22-day delay in implementing the prescribed care for a non-pressure wound on the resident's shin. Interviews revealed that the Wound Physician expected notification if orders were not followed, and staff were responsible for entering treatment recommendations into the clinical record.
A resident with dementia and Parkinson's disease did not receive necessary assistance with ADLs, including meal supervision and nail care, as outlined in their care plan. Observations showed the resident was left unsupervised during meals, struggling with tasks like opening milk cartons, and had elongated fingernails due to lack of grooming assistance. Communication lapses among staff contributed to the deficiency, as the resident's Kardex did not specify the required level of assistance, and staff were unaware of the supervision needs.
A facility failed to adhere to infection control standards for a resident with an indwelling catheter. The resident's urinary catheter drainage bag and tubing were repeatedly observed in direct contact with the floor, contrary to facility policy. The resident, who was cognitively intact but physically dependent on staff for catheter management, reported frequent issues with the drainage bag being on the floor and leaking. Staff acknowledged the importance of keeping the catheter equipment off the floor to prevent infection.
A resident with dementia and Parkinson's disease was found to have bed rails installed without a prior safety assessment for entrapment risks. The facility's policy requires such assessments upon admission, but it was only completed 20 days later after surveyor intervention. Staff interviews confirmed the oversight, highlighting a lapse in following safety protocols.
The facility failed to limit PRN psychotropic medications to 14 days for a resident with dementia and anxiety disorder, and did not conduct required AIMS assessments for another resident on antipsychotic medication. The oversight in medication management and assessment was acknowledged by the Unit Manager and Director of Nursing.
The facility did not ensure medications were dated once opened, as required by guidelines. During an inspection, a vial of heparin sodium and two vials of insulin glargine were found open and undated in a medication cart. Both Nurse #3 and the DON confirmed that these medications should have been dated due to their shortened expiry dates once opened.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their documented code statuses. One resident was inaccurately documented as DNR by the physician and nurse practitioner, despite records indicating a full code status. Another resident's physician order was documented as full code, while the MOLST indicated DNR/DNI. These inconsistencies were confirmed by the Unit Managers and the DON.
The facility failed to maintain sufficient staffing levels, leading to inadequate care for residents. Observations revealed only one CNA for 18 residents, and interviews confirmed the difficulty in providing care. Two residents reported long wait times and insufficient assistance due to the staffing shortage.
The facility failed to serve food that is palatable, and at a safe and appetizing temperature on two units. Test trays revealed that food temperatures were not within the acceptable range, with items being either warm, lukewarm, or cold, and some having undesirable textures and tastes. The Registered Dietitian confirmed significant temperature drops from the kitchen to the unit, indicating a failure to maintain proper food temperatures during service.
The facility staff failed to ensure an effective QAPI plan was in place, as evidenced by the lack of prioritizing processes, root cause analyses, and tracking of intervention outcomes. Interviews revealed a lack of awareness and communication regarding the water management program and environmental issues, with no QAPI plans addressing staffing and food quality concerns.
The facility failed to ensure proper infection control practices during medication administration and did not complete a risk management assessment for legionella. A nurse did not perform hand hygiene after removing gloves and used a wet blood pressure cuff on a resident. The facility also lacked proper documentation and adherence to its water management policies.
The facility failed to maintain resident rooms in good repair, clean, and homelike on two of three care units. Observations revealed broken furniture, missing tiles, stained toilet seats, exposed cement, large cracks in windows, water stains on ceilings, and peeling wallpaper. The Director of Maintenance admitted to incomplete maintenance requests, and the Administrator was unaware of the issues. Interviews revealed that broken windows identified last year were deemed unsafe but were not replaced.
The facility had a medication error rate of 12.12%, with two nurses making multiple errors in administering medications to two residents. Errors included incorrect timing and dosage, and failure to follow physician's orders and pharmacy recommendations.
The facility failed to conduct comprehensive mattress inspections, neglecting zone 7 and resulting in significant gaps for two residents. One resident had a gap greater than 12 inches between the headboard and mattress, while another had a 5.5-inch gap between the mattress and footboard. The Maintenance Director admitted to not measuring these distances, following a policy that only covered zones one through four.
The facility failed to provide a dignified dining experience for two residents. One resident with severe cognitive impairment and another with hemiparesis were observed being fed by staff members who were standing over them, not at eye level. The DON confirmed that this practice is unacceptable and violates the residents' right to dignity.
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. There was no documentation of a pre-restraining assessment, a physician's order, or a care plan intervention for the use of these pillows as restraints.
The facility failed to develop and implement a baseline care plan within 48 hours for a resident at risk for elopement. Despite the resident's history of exit-seeking behavior and wandering, care plans were delayed, and an inaccurate elopement assessment was conducted. Staff interviews confirmed the oversight and the necessity for a timely care plan.
The facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, but the medical record did not indicate a care plan addressing this issue.
A resident with dementia and essential hypertension was found with unswallowed medication due to a nurse not following the facility's policy of staying with the resident until all medication was swallowed. The nurse assumed the resident had taken the medication, but further inspection revealed otherwise.
The facility failed to provide necessary services for a resident with limited English proficiency (LEP) to effectively communicate needs. Despite the resident's dependence on staff for daily activities and a care plan requiring an interpreter and communication board, these tools were not consistently available. Staff acknowledged the communication barrier and the inadequacy of the provided resources.
The facility failed to supervise a resident with Alzheimer's and epilepsy during meals, despite the care plan indicating the need for supervision. The resident was observed eating alone multiple times, leading to incidents of profuse coughing and near choking. Staff were present nearby but did not provide the necessary assistance.
A resident experienced significant weight loss due to the facility's failure to implement the RD's recommendation to increase the frequency of nutritional supplements. Despite documented recommendations, the necessary physician orders were not placed, resulting in continued inadequate supplementation.
The facility failed to provide trauma-informed care for two residents with PTSD by not conducting trauma assessments per policy and not developing comprehensive care plans that include triggers for re-traumatization. One resident had intact cognition, while the other had moderate cognitive impairment. The Social Worker acknowledged the need for better documentation of PTSD triggers and care plans.
A resident with celiac disease was served a meal containing gluten despite their dietary restrictions. The cook added wheat-containing gravy to the resident's meal, contrary to the facility's policy and the resident's meal ticket instructions.
The facility failed to handle food in accordance with professional standards, with staff repeatedly touching resident food directly with their bare hands during meal set-up and feeding assistance. Observations during breakfast and lunch revealed multiple instances of non-compliance with the facility's policy, which mandates the use of gloves when handling food.
Failure to Assess Potential Restraints Used in a Resident’s Bed
Penalty
Summary
The facility failed to identify and assess the use of pillows and a blanket tucked under a fitted sheet on both sides of Resident #74’s bed, as well as a geri-chair placed directly next to the bed, as potential restraints. The facility policy stated that restraint use is limited to circumstances in which a resident has medical symptoms that warrant it, and that a physician’s order alone is not sufficient. Resident #74 was admitted with diagnoses including paranoid schizophrenia, bipolar disorder, epilepsy, and dementia, and the most recent MDS indicated severe cognitive impairment and inability to participate in the Brief Interview for Mental Status exam. On 1/29/26, the surveyor observed the resident sleeping on the left side in bed with padded side rails in use on both sides. The surveyor observed significant humps under the fitted sheet on both the right and left sides of the mattress, and upon lifting the sheet found pillows and blankets stuffed underneath it. A geri-chair was also positioned directly next to the right side of the bed. CNA #1 and the Unit Manager both observed the setup and stated it looked like a restraint and should not have been done. CNA #1 said the resident was fully dependent for ADLs and often became restless and tried to get out of bed, while the Unit Manager said the resident was a fall risk and unpredictable. Review of the resident’s physician orders, admission assessment, fall risk evaluations, and care plans did not show an order, assessment, or care plan entry for pillows or blankets tucked under the fitted sheet or for the geri-chair being used as a potential restraint. The record also did not contain a restraint assessment or device assessment for these items. Nursing and CNA interviews did not explain why the pillows, blanket, or geri-chair were used in this manner, and the DON later identified a CNA as the person who placed the pillows and blanket under the fitted sheet.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident #7, who was admitted with multiple sclerosis and dementia, had a Stage IV pressure wound on the left ischium and an unstageable pressure injury on the lower sacrum. The facility did not implement the treatment recommendations made by the consultant Wound Physician, which included the use of specific dressings such as Mesalt, Plurogel, and superabsorbent gelling fiber. Instead, the facility continued using Santyl and Mupirocin ointments, which were not recommended by the Wound Physician. The orders also failed to follow the recommended frequency of dressing changes, which was once daily, and did not include the use of superabsorbent gelling fiber as indicated by the Wound Physician. Resident #26, who was admitted with multiple sclerosis and failure to thrive, had a Stage IV pressure ulcer on the sacrum. The facility did not follow the Wound Physician's recommendations for dressing treatment, which included the use of Mupirocin, Alginate calcium, Santyl, and superabsorbent gelling fiber with silicone border. The facility's orders included a dry protective dressing instead of the recommended superabsorbent gelling fiber, and the application of skin prep to the peri-wound was not implemented. The Wound Nurse responsible for transcribing the physician's orders admitted to not implementing the Wound Physician's recommendations and did not notify the Wound Physician of the changes made to the treatment plan. Interviews with the Wound Physician and the Director of Nursing revealed that the facility did not notify the Wound Physician when his treatment orders were not being implemented. The Wound Physician expected to be informed if his recommendations were not followed, and the Director of Nursing stated that all wound consultant treatment recommendations should be addressed and documented if not implemented. The failure to implement the Wound Physician's recommendations and the lack of communication regarding these changes contributed to the deficiencies in pressure ulcer care for the residents.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The surveyor noted several instances of improper food storage and handling, including undated deli ham, chicken, biscuit dough, and hotdogs in the walk-in refrigerator. Additionally, there were open containers of apple juice and personal items like kombucha stored near resident food. In the unit kitchenettes, open and undated bottles of orange and apple juice were found, along with a sandwich past its use-by date. These observations indicate a lack of compliance with the facility's policy on labeling and dating food items, which is essential for ensuring food safety and minimizing waste. Furthermore, the facility served undercooked unpasteurized eggs to residents, which poses a significant risk for Salmonella infection, especially for the elderly and immunocompromised individuals. During the survey, it was observed that residents were served fried eggs with runny yolks, and the eggs used were not confirmed to be pasteurized. The Food Service Director confirmed that unpasteurized eggs should be cooked until the yolk is firm, and the Corporate Food Service Director acknowledged the lack of proper labeling and dating of food items, as well as the inappropriate storage of personal drinks in the facility's freezer.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as required by their care plans and facility policy. Resident #76, who was cognitively intact, was observed being washed by a CNA who wore gloves but not a precaution gown, despite a sign indicating the need for enhanced barrier precautions. Similarly, Resident #24, who had severe cognitive impairment, was observed having bed linens changed by a CNA who also wore gloves but not a precaution gown. Interviews with the Unit Manager and Director of Nursing confirmed that staff were required to wear both gloves and a precaution gown during high-contact activities for residents on enhanced barrier precautions. The facility also failed to ensure proper hand hygiene during wound care for Resident #26, who had a stage four pressure ulcer. A wound nurse was observed changing the resident's dressing without sanitizing her hands after removing soiled gloves and before applying new ones. The nurse acknowledged the lapse in hand hygiene during an interview, which was contrary to the facility's hand hygiene policy that requires sanitizing hands before and after using personal protective equipment. Additionally, the facility did not sanitize shared resident equipment between uses. A nurse was observed using a vitals machine on two different residents without disinfecting it in between. The nurse admitted to not disinfecting the equipment, and the Director of Nursing was unaware of the requirement to sanitize shared equipment between resident uses, as per CDC recommendations. This oversight in infection control practices was noted during the surveyor's observations.
Failure to Provide Dignified Dining Experience in Dementia Unit
Penalty
Summary
The facility failed to provide a dignified dining experience for residents residing on the dementia unit, as observed by surveyors. On multiple occasions, residents were observed waiting for their meals while their tablemates were already eating. For instance, during breakfast on the View Unit, some residents were served while others watched, leading to situations where residents asked if the meals being served were theirs or even took food from their tablemates. This pattern was consistent across different meal times, with significant delays between the first and last residents being served at the same table. The Director of Nursing acknowledged the issue, noting that the unpredictability of residents' seating arrangements contributed to the difficulty in serving meals simultaneously. Despite this acknowledgment, the observations clearly indicated a failure to ensure that all residents were served their meals in a timely and dignified manner, which is a fundamental right of the residents. The deficiency was evident in the repeated instances of residents having to wait and watch others eat, which compromised their dining experience.
Failure to Implement Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with paranoid schizophrenia, legal blindness, and malnutrition. The resident was admitted in March 2019 and had a recent Minimum Data Set (MDS) assessment indicating moderate cognitive impairment and severely impaired vision. Despite physician's orders for a dysphagia advanced/ground texture diet and the use of a lip plate to aid in eating, the resident was observed eating meals on a regular plate without staff supervision or assistance on multiple occasions. The resident's care plan did not reflect the need for an altered diet or the use of adaptive equipment, and staff were unaware of these requirements. The Unit Manager and Director of Nurses acknowledged the oversight, indicating a lack of adherence to the facility's policy on comprehensive person-centered care plans. This failure to implement the care plan as prescribed resulted in the resident not receiving the necessary supervision and adaptive equipment during meals.
Failure to Revise Care Plan for Resident's Eating Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, specifically regarding tube feeding and risk for choking, after two quarterly assessments. The resident, who was cognitively intact, required setup assistance with eating and did not receive tube feeding, as indicated in the Minimum Data Set (MDS) assessments. Despite this, the care plan included interventions for tube feeding and elevating the head of the bed, which were not applicable to the resident's current condition. Observations revealed that the resident was lying flat in bed while eating, which contradicted the care plan's interventions. The resident expressed discomfort with elevating the head of the bed due to pain from a pressure sore and arthritis, preferring to eat while lying flat. Staff interviews confirmed that the resident had not received tube feeding and only ate by mouth. The interdisciplinary team (IDT) failed to update the care plan to reflect the resident's current needs and preferences, despite being aware of the resident's condition and preferences for at least six months. The care plan meetings, which should have included revisions to the care plan, did not address the resident's inability to tolerate head elevation or the absence of tube feeding. Various staff members, including the Unit Manager, Dietitian, Occupational Therapist, and Speech Therapist, acknowledged that the care plan interventions were inappropriate and should have been revised. The Director of Nursing also confirmed that the care plan should have been updated to include the resident's noncompliance with head elevation during meals.
Failure to Implement Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with multiple sclerosis and dementia. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had two existing pressure areas. The deficiency was identified when the facility did not implement wound treatments as ordered by the consultant Wound Physician for a non-pressure wound on the resident's left upper shin. The Wound Physician had documented treatment recommendations on multiple occasions, but the facility did not begin implementing these treatments until 22 days after the initial order. The facility's policy on wound treatment management required that wound treatments be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Despite this policy, the treatment administration records showed a significant delay in the implementation of the prescribed wound care. Interviews with the Wound Physician and Wound Nurse revealed that the physician expected to be notified if his orders were not being implemented, and the nurse confirmed that staff were responsible for inputting the physician's treatment recommendations into the clinical record. This lapse in care highlights a failure in the facility's processes to ensure timely and accurate implementation of physician orders.
Failure to Provide ADL Assistance for Resident with Dementia and Parkinson's
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with dementia and Parkinson's disease, identified as Resident #55. The resident required supervision or touching assistance for eating and substantial assistance with personal hygiene, as indicated in their care plan and occupational therapy evaluation. However, observations revealed that the resident was left unsupervised during meals on multiple occasions, struggling to open milk cartons and spilling milk on themselves, without any staff present to assist. Additionally, the facility did not provide adequate nail care for the resident. Observations noted that the resident's fingernails were elongated and protruding, indicating a lack of regular grooming assistance. Interviews with staff confirmed that the resident typically allows staff to assist with grooming, and the Director of Nursing stated that staff should offer assistance with nail care and document any refusals, which was not done in this case. The deficiency was further compounded by communication lapses among staff. The Director of Rehab expected staff to supervise the resident during meals, but the Unit Manager was unaware of this requirement, and the resident's Kardex did not specify the level of assistance needed for eating. This lack of communication and documentation led to the resident not receiving the necessary care and supervision as outlined in their care plan.
Failure to Maintain Infection Control for Urinary Catheter Care
Penalty
Summary
The facility failed to maintain professional standards in managing and caring for urinary catheter devices for a resident with an indwelling catheter. The resident, who was cognitively intact and required assistance for mobility and toileting, had a urinary catheter drainage bag and tubing that were repeatedly observed to be in direct contact with the floor. This was contrary to the facility's policy, which specified that catheter tubing and drainage bags should be kept off the floor to prevent infection. The resident reported that the drainage bag was often on the floor and sometimes leaked, and stated that they were dependent on staff for catheter management due to physical limitations. Multiple observations by the surveyor confirmed that the urinary drainage bag and tubing were not properly secured and were in contact with the floor on several occasions. Staff members, including a CNA and the Unit Manager, acknowledged that the drainage bag and tubing should not touch the floor due to infection control concerns. The Director of Nursing also confirmed that the drainage bags and tubing should never be directly touching the floor, indicating a lapse in adherence to infection control protocols.
Failure to Assess Bed Rail Safety for Resident
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for a resident, identified as Resident #55, who was admitted with diagnoses of dementia and Parkinson's disease. The deficiency was identified when it was observed that the resident's bed was equipped with side rails on both sides without a prior assessment for risk of entrapment. The facility's policy requires an interdisciplinary team to assess the resident's sleeping environment, including the use of side rails, to prevent injuries or deaths from bed-related equipment. However, this assessment was not completed for Resident #55 until 20 days after admission, following the surveyor's intervention. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, revealed that side rail assessments should be completed upon admission and before the use of side rails. The Director of Maintenance confirmed that while the maintenance department assesses beds for entrapment risks annually and upon new admissions, there was no evidence of such an assessment for Resident #55's bed after their admission. This oversight led to the deficiency being cited during the survey.
Failure to Limit PRN Psychotropic Medications and Conduct AIMS Assessments
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications and were properly assessed for adverse reactions to psychotropic medications. For one resident, the facility did not limit the use of PRN psychotropic medications to 14 days as required by their policy. The resident, who was admitted with diagnoses including unspecified dementia with agitation and anxiety disorder, received doses of lorazepam without a stop date, contrary to the facility's policy. The Unit Manager acknowledged the oversight and indicated the need to discuss scheduling the medication with the physician. Another resident, admitted with diagnoses including heart failure, Alzheimer's Disease, and chronic kidney disease, did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed as required. The resident was receiving antipsychotic medication, and the most recent AIMS assessment was completed over a year ago, despite the facility's policy requiring such assessments quarterly or with significant changes. The Director of Nursing confirmed the expectation for AIMS assessments to be completed every six months for residents on antipsychotic medications.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to comply with State and Federal requirements for the storage of drugs and biologicals, as observed by surveyors. During an inspection of the Court unit medication cart, it was found that one vial of heparin sodium injection solution and two vials of insulin glargine subcutaneous solution were open and undated. This is contrary to the manufacturer's guidelines, which require these medications to be dated once opened due to their shortened expiry dates. Nurse #3 confirmed that the medications should have been dated when opened, and the Director of Nursing also acknowledged this requirement during an interview.
Inaccurate Documentation of Code Status for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their documented code statuses. For one resident, the physician and nurse practitioner inaccurately documented the resident's code status as Do Not Resuscitate (DNR) when the resident's Medical Orders about Life-Sustaining Treatment (MOLST) and other records indicated a full code status, meaning resuscitation should be attempted. This inconsistency was confirmed during an interview with the Unit Manager, who acknowledged the error in the documentation by the physician and nurse practitioner. For another resident, the facility inaccurately documented the resident's physician's order as a full code, while the resident's MOLST indicated a DNR and Do Not Intubate (DNI) status. This discrepancy was identified during a review of the resident's records and confirmed by the Unit Manager, who noted that the MOLST should match the physician's order to ensure clarity for the nursing staff. The Director of Nursing also confirmed that the MOLST should align with the physician's order, highlighting the facility's failure to maintain consistent and accurate medical records.
Facility Fails to Maintain Sufficient Staffing Levels
Penalty
Summary
The facility failed to maintain sufficient staffing levels to adequately meet residents' care needs. On 2/27/24, the surveyor observed only one CNA working on the Court Unit, which housed 18 residents. The Director of Nursing acknowledged that staffing has been an ongoing challenge. The facility assessment indicated that 33 full-time equivalent CNAs were needed daily, but actual staffing ranged from 18 to 24 CNAs per day. Interviews with staff confirmed the difficulty in providing adequate care due to insufficient staffing levels. The Administrator admitted to being aware of the staffing issues but had not implemented any new initiatives to enhance CNA recruitment. Two residents, one admitted in November 2023 with anxiety and depression and another admitted in September 2023 with cancer and traumatic brain injury, reported not receiving timely care due to the staffing shortage. Both residents, who were cognitively intact, expressed frustration over long wait times for assistance and inadequate care. One resident mentioned having to wheel themselves into the hallway to find help, while the other reported not receiving showers as often as desired. The Director of Nursing also noted that the acuity levels of residents had increased over the past several months, further exacerbating the staffing issue.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food that is palatable, and at a safe and appetizing temperature on two out of two units. During a group meeting, all 12 participants reported that the food was not hot when served. Test trays conducted on the Meadows Unit and the Dementia Unit revealed that the food temperatures were not within the acceptable range. Specifically, on the Meadows Unit, the meatloaf was 90 degrees Fahrenheit, green beans were 80 degrees Fahrenheit, potatoes were 84 degrees Fahrenheit, apple pie was 60 degrees Fahrenheit, milk was 40 degrees Fahrenheit, and apple juice was 50 degrees Fahrenheit. On the Dementia Unit, the meatloaf was 135.1 degrees Fahrenheit, green beans were 123.4 degrees Fahrenheit, potatoes were 132.6 degrees Fahrenheit, apple pie was 52.3 degrees Fahrenheit, milk was 55 degrees Fahrenheit, and apple juice was 54.4 degrees Fahrenheit. The food items were described as either warm, lukewarm, or cold, and some had undesirable textures and tastes, such as being bland, grainy, gritty, or gummy. The Registered Dietitian (RD) confirmed that the facility conducts periodic test trays and provided results from a previous test tray conducted on 12/5/23. The results showed significant temperature drops from the kitchen to the unit, with hot foods falling below the acceptable range of greater than 120 degrees Fahrenheit and cold foods exceeding the acceptable range of less than 50 degrees Fahrenheit. For example, a hot dog measured 140 degrees Fahrenheit in the kitchen but only 110 degrees Fahrenheit on the unit, and milk measured 40 degrees Fahrenheit in the kitchen but 60 degrees Fahrenheit on the unit. The RD stated that the metrics used to evaluate test trays are outlined on the test-tray form, indicating a failure to maintain proper food temperatures during service.
Ineffective QAPI Plan and Lack of Performance Improvement
Penalty
Summary
The facility staff failed to ensure an effective Quality Assurance Performance Improvement (QAPI) plan was in place. The review of the QAPI meeting minutes for 2023 revealed that the facility did not implement a prioritizing process, complete root cause analyses for identified problems, or track outcomes for interventions to determine their effectiveness. Specifically, the December 2023 QAPI meeting minutes did not show that performance improvement plans were implemented for known areas of concern, including adequate staffing, food quality, environmental concerns, and the continuation of the water management program. Interviews with the Maintenance Director and the Administrator highlighted a lack of awareness and communication regarding the water management program and environmental issues. The Maintenance Director was unable to speak to the water management program and only provided a risk assessment for legionella on the day of the interview. The Administrator admitted to relying on the Maintenance Director for updates on environmental issues and was unaware of the water management program issues. Additionally, the Administrator acknowledged concerns with staffing and food quality but confirmed that no QAPI plans were in place to address these issues.
Infection Control and Legionella Risk Management Deficiencies
Penalty
Summary
The facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, during a medication pass, a nurse did not perform hand hygiene after removing gloves and before administering medication to a resident. The nurse also used a wet blood pressure cuff on the resident and stacked medication cups, which are not clean on the bottom, inside one another. The Director of Nurses confirmed that the nurse should have used hand sanitizer before and after removing gloves and before administering medication, and should have waited for the disinfectant to dry before using the equipment. Additionally, the facility failed to complete a risk management assessment for the possible development and spread of legionella. The Maintenance Director was unable to confirm if the facility had a water management program or how the facility assesses the risk of legionella. The risk assessment was only completed during the survey, and the Administrator could not find a previously completed risk assessment, indicating a lack of proper documentation and adherence to the facility's water management policies.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure resident rooms were maintained in good repair, clean, and homelike on two of three resident care units. Observations on the Meadow unit revealed multiple deficiencies, including nightstands with dark scuff marks, chipped paint, and bubbling paint on pull-out drawers. Bathrooms had dark scuff marks, chipped paint, and discoloration. Several rooms had broken furniture, missing tiles, stained toilet seats, and exposed cement. Additionally, there were large cracks in windows, water stains on ceilings, and peeling wallpaper. The hallways on the Meadow unit also had black scuff marks on the walls, and a large water stain was observed on the ceiling above the water fountain entering the unit. On the View unit, similar issues were observed. A water fountain was attached to the wall with visible cracked plaster and chipped paint. Resident rooms had broken furniture, holes in doors, peeling wallpaper, and stained floor tiles. The Director of Maintenance (DOM) admitted to conducting monthly environmental rounds but failed to document and complete maintenance requests. The DOM also mentioned that only a few staff members were trained to use the online reporting system for tracking building issues. The Administrator was unaware of the environmental issues and relied on the DOM to inform her of any problems. Interviews with the Regional Director of Maintenance (RDOM) and the Director of Nurses (DON) revealed that broken windows identified last year were deemed unsafe but were not replaced. The RDOM did not follow up to ensure the windows were fixed, and the DON emphasized that broken windows are a safety concern for residents and should be addressed immediately. The facility's failure to maintain a safe, clean, and homelike environment for residents was evident in the numerous deficiencies observed and the lack of timely corrective actions.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5%, with two nurses making 4 errors out of 33 opportunities, resulting in a medication error rate of 12.12%. For Resident #23, Nurse #5 administered Glipizide within 30 minutes of the resident eating breakfast, contrary to the physician's order to administer the medication 30 minutes before meals. Nurse #5 acknowledged the mistake during an interview, stating that she should have followed the order to wait 30 minutes before meals. For Resident #28, Nurse #2 made multiple errors while administering medications. The nurse did not give the correct Vitamin D3 + Calcium tablet and did not administer the correct dose of Vitamin B12. Additionally, Nurse #2 administered Levothyroxine with Iron and Calcium, which should have been separated by 4 hours as per the medication card instructions. Both the unit manager and the Director of Nursing confirmed that the medications should have been administered as per the physician's orders and pharmacy recommendations.
Failure to Ensure Comprehensive Mattress Inspections
Penalty
Summary
The facility failed to ensure a comprehensive inspection system for resident mattresses, specifically neglecting to evaluate zone 7 for potential entrapment hazards. The facility's policy only covered zones one through four, which led to the oversight of significant gaps in zone 7 for two residents. Resident #67, diagnosed with PTSD and major depressive disorder, was observed with a gap greater than 12 inches between the headboard and the mattress. Resident #67 also mentioned that the mattress was too short. Resident #72, who had severe cognitive impairment and was dependent on staff for daily living due to a stroke, was found with a 5.5-inch gap between the mattress and the footboard. A gap filler had been placed but had fallen below the mattress, rendering it ineffective. During an interview, the Maintenance Director admitted to not measuring the distance from the mattress to the headboard or footboard, following the facility's policy that only addressed zones one through four. This failure to adhere to comprehensive guidelines for bed safety, as outlined by the FDA's Hospital Bed System Dimensional and Assessment Guidance, resulted in the potential hazard of entrapment for the residents. The facility's policy did not align with the recommended safety measures, leading to the identified deficiencies.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, Resident #80 and Resident #85. Resident #80, who has severe cognitive impairment due to Alzheimer's Disease and is dependent on staff for partial/moderate feeding assistance, was observed being fed by a staff member who was standing over them, not at eye level. This observation was made in the dining room of the View unit. Similarly, Resident #85, who has diagnoses including stroke and hemiparesis or hemiplegia and is dependent on staff for substantial/maximum feeding assistance, was observed being fed by a staff member who was also standing over them and not at eye level in their room. The resident's bed was not raised during the feeding assistance. During an interview, the Director of Nursing (DON) confirmed that staff should always be seated and at eye level with a resident while providing feeding assistance. The DON acknowledged that it would be unacceptable for staff to stand over a resident while providing feeding assistance, as this would be a dignity issue. The facility's policy on Resident Rights also indicates that residents have the right to be treated with respect and dignity.
Failure to Assess and Document Use of Pillows as Restraints
Penalty
Summary
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, which were intended to prevent the resident from falling out of bed. However, there was no documentation of a pre-restraining assessment, a physician's order, or a care plan intervention for the use of these pillows as restraints. Additionally, the medical record did not indicate any restraint elimination assessment to determine the least restrictive method for the least amount of time. Interviews with staff revealed that the pillows were placed to prevent the resident from falling out of bed due to restlessness and attempts to get out of bed, particularly at night. The Director of Nursing confirmed that the use of pillows under the fitted sheet would constitute a restraint if the resident was capable of moving in bed and acknowledged that a pre-restraining assessment should have been completed. The facility's failure to follow its own policy on the use of restraints led to this deficiency.
Failure to Develop Baseline Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was at risk for elopement. The resident, admitted with a diagnosis of dementia, had a history of exit-seeking behavior and a previous elopement incident. Despite this, the care plans were not initiated until six days after admission. The elopement assessment conducted was inaccurate, stating that the resident had not exhibited wandering behaviors in the last 60 days and was not at risk for elopement, contrary to the resident's documented history and observed behaviors upon admission. Interviews with facility staff, including a CNA, a nurse, the unit manager, and the DON, confirmed that the resident was known to be at risk for elopement and that the elopement assessment was inaccurate. The staff acknowledged that a baseline care plan specific to wandering and elopement should have been developed within 48 hours of admission. The facility's policy requires that baseline care plans be developed within 48 hours to address immediate care and safety needs, which was not adhered to in this case.
Failure to Develop Care Plan for Potential Restraint
Penalty
Summary
The facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, which the Director of Nursing acknowledged could constitute a restraint if the resident is capable of moving in bed. Despite these observations, the medical record did not indicate the development of a care plan addressing the use of these pillows as restraints.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of practice for medication administration for a resident with dementia and essential hypertension. The resident, who had severely impaired cognition, was observed alone in their room with a pill in their hand and two additional pills in a cup of water. The nurse responsible for administering the medication did not stay with the resident to ensure that the medication was swallowed, as required by the facility's policy. The nurse admitted to thinking that the resident had swallowed the pills, but upon further inspection, it was found that the resident had not. The Director of Nursing confirmed that it is the facility's expectation for nurses to stay with residents until all medication is swallowed and to check for any pocketed medication. This lapse in procedure led to the resident not taking their prescribed hypertension medications properly.
Failure to Provide Adequate Communication Services for LEP Resident
Penalty
Summary
The facility failed to provide necessary services to ensure a resident with limited English proficiency (LEP) could effectively communicate his/her needs. The resident, who was admitted with diagnoses including stroke and hemiparesis, was dependent on staff for various activities of daily living and required an interpreter. Despite this, the facility did not provide adequate translation services or communication tools, such as a communication board, to facilitate interaction between the resident and staff. The resident's preferred language was Russian, and the care plan indicated the use of a translator, specifically the resident's son, and a communication board, neither of which were consistently available or utilized by the staff during the surveyor's observations. During multiple observations, the surveyor noted that the resident's son, who was identified as the primary translator, was not present, and there was no communication board in the resident's room. Staff members attempted to communicate with the resident in English, which the resident did not understand. The resident's room contained English-language materials, such as a TV and magazines, which were not useful for the resident. Staff members, including CNAs and nurses, acknowledged the communication barrier and the absence of appropriate tools to facilitate communication. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed that the interventions listed in the resident's communication care plan were not being implemented. The DON and other staff members admitted that the scrap piece of paper with a few translated words was inadequate for meeting the resident's communication needs. The lack of a comprehensive communication board and the reliance on the resident's son, who was not always present, contributed to the resident's inability to effectively communicate his/her needs, leading to a deficiency in the care provided by the facility.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to ensure supervision with meals for Resident #44, who has diagnoses including Alzheimer's disease and epilepsy, and is noted to have moderately impaired cognition. The resident's care plan indicated the need for supervision during meals, but this was not consistently provided. On multiple occasions, the resident was observed eating alone in their room without staff supervision, leading to incidents of profuse coughing and near choking. Despite the presence of staff nearby, no immediate assistance was provided to the resident during these episodes. On one occasion, the surveyor observed Resident #44 coughing profusely while eating lunch alone in their room. Although staff were present in the hallway and a nurse was feeding another resident across the hall, no one responded to the resident's distress. The resident later expressed fear about the choking incident. Similar observations were made during breakfast the following day, where the resident was again left unsupervised and began coughing on a bite of food. The surveyor had to intervene as no staff were present to assist. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan requirements. A nurse admitted to not being informed about the resident's need for meal supervision, and a CNA acknowledged that supervision should involve staying with the resident for the entire meal. The Nurse Unit Manager and the Director of Nursing confirmed that the resident should be supervised during meals, whether in the dining room or in their room, but this protocol was not followed, leading to repeated instances of the resident being left unsupervised during meals.
Failure to Implement RD's Nutritional Supplement Recommendations
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident, identified as Resident #13, who experienced significant weight loss over several months. Despite recommendations from the Registered Dietitian (RD) to increase the frequency of nutritional supplements from twice a day to three times a day, these recommendations were not implemented. The RD's recommendations were communicated verbally to nursing staff and documented, but the necessary physician orders to increase the supplement frequency were not placed. This oversight resulted in Resident #13 continuing to receive the supplement only twice a day, leading to further weight loss. Resident #13, who was admitted with diagnoses including dementia and adult failure to thrive, experienced a severe and clinically significant weight loss over several months. The weight report indicated multiple instances of significant weight loss, including an 11.4-pound loss in one month and a 16.3-pound loss in another month. Despite the RD's recommendations documented on 9/21/23 and 11/9/23, the frequency of the nutritional supplement was not increased. Interviews with the RD and Unit Manager confirmed that the recommendation should have been implemented, but an error occurred when the order was re-entered incorrectly on 9/26/23.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure that residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility did not conduct an assessment for trauma per the facility policy and did not develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two residents. Resident #67, admitted in June 2021 with diagnoses including PTSD and major depressive disorder, had a care plan that failed to indicate triggers for re-traumatization and how the resident exhibits an activation of PTSD when it occurs. The Minimum Data Set (MDS) assessment indicated that Resident #67 had intact cognition with a score of 15 out of 15 on the Brief Interview for Mental Status exam. Similarly, Resident #24, admitted in September 2022 with a diagnosis of PTSD, had a care plan that did not indicate triggers for re-traumatization and how the resident exhibits an activation of PTSD when it occurs. The most recent MDS indicated that Resident #24 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. During an interview, the Social Worker (SW) acknowledged that she tries to find out the resident's triggers through conversation and observation but admitted that the PTSD triggers should be documented in the care plan along with how the resident exhibits PTSD and how to help during a triggered episode. The SW also mentioned that she puts a PTSD care plan in the resident's medical record when she sees the PTSD diagnosis, and her consultant reviews the care plans periodically.
Failure to Accommodate Gluten Intolerance for Resident with Celiac Disease
Penalty
Summary
The facility failed to accommodate a food intolerance for a resident with celiac disease, resulting in the resident being served gluten-containing food. The resident, who was admitted with a diagnosis of celiac disease and required a gluten-free diet, was observed being served a meal with gravy containing wheat. This was despite the resident's meal ticket indicating a gluten-free requirement and the facility's policy to offer appropriate substitutions for food intolerances. During the observation, the cook prepared a meal with a gluten-free roll and beef patty but added gravy made from a mix containing wheat. The Food Service Director confirmed that the gravy should not have been served to the resident. The Registered Dietitian also stated that residents with celiac disease should not consume gluten as it could lead to intestinal damage. The incident highlights a failure in the facility's adherence to dietary restrictions for residents with specific food intolerances.
Failure to Adhere to Food Handling Standards
Penalty
Summary
The facility failed to handle food in accordance with professional standards for food service safety, specifically by allowing nursing staff to touch resident food directly with their bare hands during meal set-up and feeding assistance in the dining room of the View unit. Observations made by the surveyor during breakfast and lunch meals on 2/27/24 revealed multiple instances where staff members picked up residents' toast, opened milk containers, and handled sandwiches and hot dogs with their bare hands before serving them to the residents. These actions were in direct violation of the facility's policy, which prohibits bare hand contact with food and mandates the use of gloves when handling food directly. Interviews conducted with the Food Service Director and the Director of Nursing confirmed that staff should not be touching ready-to-eat food with their bare hands and that gloves should be used. Despite this policy, the surveyor observed repeated instances of non-compliance, indicating a systemic issue with food handling practices in the facility. No specific details about the medical history or condition of the residents involved were provided in the report.
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 1,204 citations issued within 25 miles in the last 12 months — including the 2 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 North Reading
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oc Reading Center Llc | 2.4 mi | ★★★★★ | 19 | 0 |
| Andover Forest Post Acute Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Willow Brook Rehabilitation And Healthcare Center | 3.9 mi | ★★★★★ | 30 | 0 |
| Vantage At Andover Llc | 4.3 mi | ★★★★★ | 38 | 0 |
| Care One At Wilmington | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.