Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meridian Center during CMS and state inspections, most recent first.
Undated food items were found in the reach-in refrigerator, including applesauce cups removed from original packaging, a pudding-like food item in a metal bowl with plastic wrap no longer covering it, and poured cups of thickened liquid. In a separate observation, a kitchen staff member handled cucumbers with bare hands while preparing resident food, and the DM stated staff were required to wear gloves when handling food.
A cognitively intact resident was pressured into ordering a staff meal through an online food delivery service, and the staff member failed to reimburse him for the cost. The resident reported the issue to the RN supervisor, and the DON and Administrator later confirmed the staff member had agreed to pay him back but did not.
Failure to Provide Requested Nail Care: A dependent resident with HTN, communication deficit, visual loss, and chronic pain syndrome had long, jagged fingernails noted on repeated observations. The resident said he preferred short nails, had asked staff multiple times to cut them, and felt frustrated when his requests were not met. Staff stated nail care was provided on shower days or as needed, but the UM, DON, and Administrator could not explain why the care was not provided.
Failure to Arrange Neurosurgery Follow-Up for Post-Op Staples: A resident admitted after a C4-T2 posterior fusion had a posterior neck incision with staples documented on admission, but the chart showed no neurosurgery follow-up appointment or staple-removal guidance from the hospital discharge paperwork. Facility notes repeatedly recorded the surgical wound, yet staff did not contact the neurosurgeon’s office for instructions. Interviews with the DON, Wound Care Nurse, Medical Director, and Neurosurgery office nurse confirmed that follow-up was expected and that staples are generally removed about 2 weeks post-op, but no facility call had been made until later.
A resident with stroke-related hemiplegia and dependent bathing needs was left unattended on a shower stretcher when an NA stepped out to get linen/towels. The stretcher side rails were left down, and the resident rolled off the stretcher onto the floor, reporting head, hip, and neck pain before being sent to the ER for evaluation; imaging was negative.
Unsecured Prescription Eye Drops Left on Medication Cart: A bottle of timolol eye drops was left unattended on top of a second-floor med cart while the assigned nurse stepped away to give another resident medications before an appointment. A Unit Manager walked past the cart without removing the medication, and two residents were nearby in the hallway. The nurse later stated she should have put the eye drops back inside the cart, and the DON said meds should not be left out when the nurse leaves the cart.
Food was not consistently palatable or served at an appetizing temperature. Several cognitively intact residents on regular diets reported burnt French toast, overcooked sausage, dry or cold meals, and food that did not taste good; one resident showed photos of repeatedly poor-quality meals and often avoided facility food. Kitchen staff and the DM observed returned trays with dark, hard French toast, and the DM noted temperature changes during transport in the closed cart.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Surveyors found that the facility did not have an infection prevention and control program in place, indicating a lack of systematic measures to address infection risks among residents and staff.
The facility did not adequately promote or facilitate a resident's right to self-determination by failing to support resident choice in care or daily activities, as required by regulation.
The facility did not notify the state mental health or intellectual disability authority or request required PASRR Level II re-evaluations after a resident with a mental disorder experienced a significant change in behavior and treatment, and after two residents with serious mental illness had significant changes in physical or mental status. Staff interviews revealed inconsistent understanding and practice regarding these regulatory requirements.
Surveyors found that a kitchen icemaker contained black and gray debris that appeared to be dripping onto the ice, and that large metal mixing bowls were stacked together while still wet, with liquid draining from them. Staff interviews revealed a lack of awareness and inconsistent cleaning practices for the icemaker, as well as improper storage of wet metalware.
A resident admitted with chronic kidney disease, type 2 diabetes, and hypertension did not have their admission MDS assessment completed within the required 14-day period. The MDS Coordinator confirmed the assessment was overdue due to being behind on work, and the Administrator stated that timely completion of MDS assessments is expected.
A resident with diabetes, seizure disorder, impaired mobility, incontinence, and other complex needs did not have a comprehensive care plan addressing all areas identified in the admission assessment and CAAs. Key care areas such as communication, self-care, incontinence, nutrition, hydration, dental care, and pressure ulcer prevention were omitted from the care plan, as confirmed by staff interviews and record review.
A quarterly MDS assessment for a resident was completed but not transmitted to CMS within the required timeframe. Staff interviews confirmed the assessment was finished on time but not submitted due to an error by the MDS Coordinator, contrary to facility expectations for timely submission.
A resident with a seizure disorder and diabetes was prescribed and received anticonvulsant medications, but the MDS assessment failed to indicate this and instead incorrectly documented that the resident received an anticoagulant. These discrepancies were confirmed through staff interviews and record reviews, revealing inaccurate MDS coding for medication administration.
A resident with a history of pain and mobility issues fell from a shower chair while being transported by a nursing assistant, resulting in severe injuries including fractures. The incident occurred when the chair got caught on the carpet, causing it to tip forward. The resident, unable to touch the ground while seated, fell and was subsequently hospitalized for surgical repair of her injuries.
A resident, who required extensive assistance with bed mobility, fell out of bed due to the failure to use a transfer/assist rail as per her care plan. The nursing assistant did not review the care plan and assumed the rails were in place, leading to the resident sustaining significant injuries. The incident highlighted a failure in ensuring the proper use of assistive devices.
A resident with moderate cognitive impairment and requiring extensive assistance for bathing did not receive showers as scheduled, violating their right to self-determination. Facility records showed inconsistencies and errors in shower documentation, with some entries made during non-standard hours. Staff interviews provided conflicting accounts of the resident's shower refusals, but no refusals were documented in nursing notes, and the care plan lacked provisions for shower refusals.
A resident with PTSD and psychosis struck another resident with severe dementia who wandered into their room, leading to an altercation. The incident was unexpected as both residents were generally pleasant and had no prior altercations.
The facility failed to report abuse allegations to APS for three residents. In one case, a resident's earphones were allegedly taken by a staff member, and APS was notified three days later. In another case, a resident alleged a nurse grabbed their arm, but APS was not contacted. In a third case, a resident-to-resident altercation occurred, and APS was not informed.
A resident with a history of stroke and spinal cord compression was found with excessively long and unkempt fingernails, some with a fungal infection, despite being dependent on staff for personal hygiene. The resident's repeated requests for nail care were not addressed, and staff interviews revealed a lack of communication and follow-through regarding the resident's needs.
The facility failed to maintain physician orders for continuous oxygen for a resident with COPD and emphysema, and did not administer oxygen at the ordered rate for another resident with COPD and CHF. One resident's oxygen orders were not maintained after hospice services ended, while another resident received a higher oxygen flow rate than prescribed. Staff interviews confirmed these deficiencies, and the Medical Director acknowledged the lack of orders.
The facility's QAPI committee failed to maintain effective procedures, leading to repeated deficiencies in resident care. A resident did not receive nail care, and previous investigations revealed failures in personal grooming and care for dependent residents. These issues highlight a pattern of the facility's inability to sustain an effective QAPI program.
A facility failed to update a resident's care plan to accurately reflect their abilities in dressing and bathing. Despite the resident's ability to dress and wash independently, the care plan inaccurately required extensive staff assistance. Interviews with the resident and a nursing assistant confirmed the resident's independence, and the MDS Nurse admitted the oversight in updating the care plan.
Undated Food Storage and Bare-Hand Food Handling
Penalty
Summary
Food items stored in the reach-in refrigerator were found not labeled or dated during the initial kitchen observation. The items included six applesauce cups that were no longer in their original packaging, one yellow pudding-consistency food item in a large metal bowl with plastic wrap lying in the food and no longer covering it, and fourteen poured cups of thickened liquid in plastic cups. During interview, the Dietary Manager stated that all food items required an expired by date when placed in alternate packaging. A separate observation found kitchen staff #2 handling two cucumbers with bare hands while preparing to cut them over a bowl of already sliced cucumbers. When asked about gloves, the staff member stopped before slicing and stated she had taken her gloves off for something else and had not replaced them before directly handling and preparing resident food. The Dietary Manager later stated staff were required to wear gloves when handling food, and the Administrator was informed of the undated food items and the staff member not wearing gloves while handling and preparing food.
Resident Money Used for Staff Meal Without Reimbursement
Penalty
Summary
The facility failed to protect a cognitively intact resident from the wrongful use of his belongings or money when a Nurse Aide accepted a meal purchased by the resident through an online food delivery service and did not reimburse him for the cost. Resident #144 stated that he felt pressured by the Nurse Aide to order the food, but that he did agree to place the order and expected repayment of $26.19. The resident reported that the staff member did not pay him back, and he later told the Administrator that the matter had been resolved after the facility refunded the amount. The resident was admitted to the facility and his quarterly MDS indicated that he was cognitively intact. The initial allegation report stated that the resident told the RN Weekend Supervisor that the Nurse Aide took his online food delivery order and did not deliver it to him. During the investigation, the DON documented that the resident said he felt pressured to order the staff member food, and the Administrator reported that the Nurse Aide acknowledged that the resident ordered the meal and that she would pay him back, but she did not do so. The facility determined that the Nurse Aide violated policy by soliciting or accepting a gratuity from a resident and terminated her employment.
Failure to Provide Requested Nail Care
Penalty
Summary
The facility failed to provide nail care for a dependent resident who was unable to perform his own personal hygiene. Resident #68 was admitted with diagnoses including essential hypertension, communication deficit, unspecified visual loss, and chronic pain syndrome. His care plan identified him as dependent on one staff member for personal hygiene, and the MDS documented that he was cognitively intact, had no refusal of care behavior, and was dependent on others for personal hygiene. During observations on multiple days, his fingernails on both hands were noted to be jagged or broken and extended past his fingertips by more than 1/2 inch. The resident stated he preferred to keep his fingernails short, had never had long nails, and long fingernails made him uncomfortable, especially with his vision loss. The resident reported that he had asked a NA at least three times to cut his nails and later stated that an NA told him she did not have time to do so. He also used his call light to request nail care, and the staff member who responded said she would let his nurse know. Although the shower log showed he received a shower, his nails remained unchanged and were still long and jagged on subsequent observation. NA #1 stated nail care was performed on shower days or as needed and that she would cut a resident's nails if they were long, even if it was not shower day. The UM, DON, and Administrator were unable to explain why the resident had not received nail care when requested or on shower days.
Failure to Arrange Neurosurgery Follow-Up for Post-Op Staples
Penalty
Summary
The facility failed to follow up with the neurosurgeon’s office regarding a post-operative appointment and staple removal guidance for a resident who had undergone a C4-T2 posterior fusion after a cervical fracture. The hospital discharge summary noted there were no follow-up visits scheduled for Neurosurgery and no guidance provided regarding the 15 staples in the surgical incision. The resident was admitted to the facility with diagnoses including non-displaced cervical fractures, acute 3-column fracture of C6, protein-calorie malnutrition, and a history of feeding tube placement. Facility documentation repeatedly identified a posterior neck surgical wound with staples, but the notes did not show any neurosurgery follow-up plan or any assessment documenting guidance about staple removal. Admission and skilled nursing evaluation notes recorded the wound as present on admission with 18 staples, and subsequent provider notes referenced the recent spinal surgery and described the skin as warm and dry without erythema. The care plan addressed surgical wound management with daily betadine to the posterior neck, but the record did not show that the neurosurgeon’s office had been contacted for instructions about the staples. During interviews, the resident’s son and daughter-in-law stated they were concerned that no neurosurgery appointment had been scheduled and that there was no plan to remove the staples. The Wound Care Nurse stated it was the admitting nurse’s responsibility to determine when the staples needed to be removed and to follow up with Neurosurgery if the discharge paperwork did not provide guidance. The DON stated she expected staff to have noticed the missing follow-up and to have called the neurosurgeon’s office, and the Medical Director stated that staff should have reached out within 14 days of admission. The Neurosurgery office nurse stated staples are generally removed about 2 weeks post-op and that the facility had not contacted the office until much later. The resident’s staples were later removed, and the resident stated the first two staples hurt when removed.
Resident Left Unattended on Shower Stretcher and Fell
Penalty
Summary
The facility failed to provide personal care in a safe manner when a resident with a history of stroke, left hemiplegia, hemiparesis, and contractures of the left wrist and hand was left unattended in the shower room while on a shower stretcher. The resident’s care plan identified a need for dependent assistance with bathing and personal hygiene, use of a shower bed/stretcher for showers, and staff presence for safety and sequencing cues. The resident was cognitively intact but dependent for rolling left and right and had impaired range of motion on one side of the body. During the shower, the nurse aide left the resident alone in the shower room to get a towel. The resident stated the side rails on the shower stretcher were down when the aide left, and he felt like he was slipping before rolling toward the left and falling off the right side of the stretcher onto the floor. The resident reported pain in his head, hip, and neck and was later transferred to the hospital for medical evaluation. The incident report documented that the resident was left unattended and found on the floor after the aide re-entered the room. Staff interviews confirmed that the resident was found lying on his back on the shower room floor and that the shower stretcher’s side rails should have been up but were left down. The nurse and weekend supervisor completed assessments and notified the physician, and the resident was sent to the emergency room for further evaluation. The emergency department report noted an unwitnessed fall with complaints of head, hip, and neck pain, and imaging studies were negative for acute injury.
Unsecured Prescription Eye Drops Left on Medication Cart
Penalty
Summary
The facility failed to secure a bottle of prescription eye drops in accordance with medication storage requirements when a bottle of timolol eye drops was left unattended on top of the second-floor medication cart outside a resident room. During a continuous observation, the cart was not attended by the nurse assigned to it, and the eye drops remained sitting on top of the cart while two residents were observed sitting in the hallway nearby. A Unit Manager walked past the cart during the observation but did not acknowledge or remove the medication. When the nurse returned to the cart, she stated she would not normally leave medications on top of the cart and explained that she had gone to a resident's room to give him his medications before he left for an appointment. She stated she should have put the eye drops back inside the medication cart before leaving it. The Unit Manager stated she did not notice the eye drops when she walked by, but would have removed them if she had seen them, and said the expectation was that the nurse would put the medication back in the cart before leaving. The DON stated she would expect the nurse to complete the medication pass first, but if she had to leave the cart, she would expect the medication to be placed back inside the cart.
Food Served Burnt, Dry, and Temperature Issues
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at a safe and appetizing temperature. During the initial kitchen observation, several returned breakfast trays contained French toast that was dark brown, shriveled at the edges, and hard to the touch, and kitchen staff and the cook had no comment about the condition of the food. Resident #14, who was cognitively intact and on a regular, liberalized diet, stated her breakfast tray arrived with burnt French toast that she could not eat and that food frequently did not taste good, was cold, dry, and overcooked. She later reported sausage that was overcooked and hard, and said she had told the nursing assistant when trays were picked up. Resident #83, also cognitively intact and on a regular, liberalized diet, stated food was frequently overdone, dry, sometimes cold, and did not taste good, and specifically reported that the French toast was badly burned and not edible and the breakfast sausage was consistently burned, dry, and hard. Resident #139, who was cognitively intact and on a regular, liberalized diet, stated the food was horrible and often not edible, showed pictures of food served at the facility, and identified the breakfast French toast as dark, flat, and shriveled, saying he could not cut it and did not eat it. He later did not eat the facility lunch and obtained food from outside the facility; on another observation, his sausage patties appeared firm like rubber, shriveled, and overcooked, and remained uneaten. The Dietary Manager stated he was unaware of the residents' palatability concerns, and during a lunch test tray he noted that hot food affected cold food temperature in the closed transport cart and that ice cream began to melt during transport.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in relation to the deficiency, and no additional details about individual medical histories or conditions were provided in the report.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations.
Failure to Notify State Authority and Request PASRR Re-Evaluations After Significant Change in Condition
Penalty
Summary
The facility failed to notify the appropriate state authorities and request required re-evaluations for residents with mental disorders or intellectual disabilities who experienced a significant change in condition. Specifically, for one resident with schizoaffective disorder, there was a documented change in behavioral symptoms, including increased agitation and psychosis, which led to new orders for antipsychotic and anti-anxiety medications. Despite these changes, the facility did not initiate a Level II PASRR screening as required when a significant change in condition occurs for individuals with mental illness. Two additional residents with serious mental illness and PASRR Level II determinations experienced significant changes in their physical or mental status, such as significant weight loss, new swallowing disorders, and functional decline. In both cases, the residents' Minimum Data Set (MDS) assessments identified these significant changes, but the facility did not request a PASRR Level II re-evaluation from the state mental health authority as required by regulation. Interviews with facility staff, including the Social Services Director, Social Worker, MDS Coordinator, Administrator, and Director of Nursing, revealed a lack of understanding and inconsistent practice regarding the requirement to notify the state authority and request PASRR re-evaluations following significant changes in condition for residents with mental illness or intellectual disabilities. This resulted in the failure to ensure appropriate notifications and screenings for all three residents reviewed who had experienced significant changes.
Unsanitary Kitchen Icemaker and Improper Storage of Wet Mixing Bowls
Penalty
Summary
Surveyors observed that one of the facility's two kitchen icemakers contained black and gray debris running down the ice divider and along the top ridge where the door opened and closed. The debris was wet and appeared to be dripping onto the ice. Additionally, three large metal mixing bowls that had recently been washed were found nested together on a storage shelf while still wet, with visible liquid draining from the bowls when separated. These conditions were directly observed during the survey. Interviews with facility staff revealed that the Dietary Manager was unaware of the debris in the ice machine and stated that the ice machine was scheduled for monthly cleaning by the maintenance department, but he did not know the specific cleaning schedule or the nature of the debris. The Maintenance Director reported that he performed deep cleaning of the ice machine every six months and had last cleaned it about three weeks prior, but admitted to missing the divider panel during the cleaning. The Administrator confirmed expectations that the ice machine should be clean and that metalware should be fully dry before stacking.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment within the required 14-day timeframe for one resident who was admitted with chronic kidney disease, type 2 diabetes, and hypertension. Record review showed that the MDS admission assessment for this resident had an assessment reference date but was not completed as required. During interviews, the MDS Coordinator confirmed that the assessment was overdue and acknowledged being behind on completing it. The Administrator stated that the expectation was for all MDS assessments to be completed on time.
Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple medical needs, as identified during the admission assessment and confirmed by staff interviews and record review. The resident had diagnoses including diabetes and a seizure disorder, with additional impairments such as limited range of motion in all extremities, use of a walker, and total dependence on staff for several activities of daily living. The Minimum Data Set (MDS) assessment and Care Area Assessments (CAAs) triggered several areas requiring care plan interventions, including communication, functional abilities, urinary incontinence, nutritional status, dehydration/fluid maintenance, dental care, and pressure ulcer/injury prevention. Despite these identified needs, the resident's current care plan did not address or include these areas of focus. Interviews with the MDS Coordinator confirmed that the comprehensive care plan was incomplete and that the areas triggered by the CAAs should have been included. The MDS Coordinator acknowledged that the care plan was not finished by the required deadline. The Administrator and DON also confirmed that a comprehensive care plan was expected to be developed in a timely manner, but this was not done for the resident in question.
Failure to Timely Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The resident was admitted to the facility and had a history of MDS assessments, with one quarterly MDS assessment documented as completed in the electronic medical record but not transmitted to the Centers for Medicare and Medicaid Services (CMS) database as required. Staff interviews confirmed that while the assessment was completed on time, it was not submitted within the mandated period due to an oversight by the MDS Coordinator. The Administrator stated that timely transmission of MDS assessments is expected.
Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the administration of anticonvulsant and anticoagulant medications. The resident, who had diagnoses including diabetes and a seizure disorder, was prescribed and received anticonvulsant medications (lamotrigine and pregabalin) as documented in the electronic medical record and Medication Administration Record. However, the MDS assessment did not indicate that the resident received anticonvulsant medications during the 7-day look back period. Additionally, the MDS assessment incorrectly reported that the resident received an anticoagulant medication, despite no evidence in the records that such medication was administered during that period. These inaccuracies were confirmed during interviews with the facility's MDS Coordinator, who acknowledged the errors after reviewing the resident's records and MDS assessment. The facility's Administrator also stated that MDS assessments are expected to be coded accurately. The deficiency was identified through staff interviews and record reviews, which revealed the discrepancies between the resident's actual medication administration and what was documented in the MDS assessment.
Resident Injury Due to Unsafe Transfer in Shower Chair
Penalty
Summary
The facility failed to ensure the safe transfer of a resident from a shower to her room, resulting in a significant accident. On June 12, 2024, a nursing assistant was transporting a resident in a shower chair when the chair tilted forward, causing the resident to fall to the floor. The resident, who was moderately cognitively impaired and totally dependent on staff for bathing and transfers, suffered severe injuries, including fractures to her left tibial plateau, right foot great toe, and right femur, which required surgical repair. The resident had a history of pain, debility, and gait abnormalities, and was at risk for falls due to impaired mobility, balance, and other factors. At the time of the incident, the resident was being pushed in a shower chair by a nursing assistant when the chair reportedly got caught on the carpet, causing it to jerk and tip forward. The resident, who was unable to touch the ground while seated in the chair, fell forward, hitting her knees and then her back, and experienced severe pain, prompting her transfer to the hospital. Interviews with staff and the resident revealed that the shower chairs were difficult to maneuver on the carpet, and the resident had not previously experienced issues with balance in the chair. The incident report noted that the fall occurred in a hallway with rugs and carpeting, which were identified as predisposing factors. The facility's Director of Nursing and other staff assessed the situation and determined that the resident should be sent to the hospital due to the severity of her pain and injuries.
Removal Plan
- Nurse #1 immediately assessed resident #1 to include vital signs, neuro checks, and pain assessment.
- Nurse #1 notified Nurse Practitioner (NP) and obtained an order to send resident #1 to the local hospital for further evaluation.
- The center recognizes that all residents that utilize shower chairs, shower stretchers and wheelchairs have the potential to be affected from the noncompliance with shower chairs, shower stretchers and wheelchairs.
- The Director of Nursing audited incidents to ensure no significant events with any other residents were identified.
- The Director of Nursing and Unit Manager conducted a quality review to identify residents' mobility status as it relates to requiring the use of wheelchairs, shower stretchers and shower chairs.
- The Maintenance Director completed a quality review on shower chairs and shower stretchers to ensure safety mechanisms were properly installed to ensure resident safety while being transported to and from the shower rooms.
- Safety belts were installed on all shower chairs.
- The Director of Nursing and/or Nursing Supervisor provided education to Licensed Nurses and Certified Nursing Assistants to include Agency Licensed Nurses and Agency Certified Nursing Assistants on Guidelines for Safe Bathing with the use of Shower Chair to prevent incidents and accidents.
- All newly hired Licensed Nurses and Certified Nursing Assistants to include newly hired Agency Licensed Nurses and Agency Certified Nursing Assistants will be educated during new hire orientation on Guidelines for Safe Bathing with the use of Shower Chair.
- The Unit Manager and/or Director of Nursing will begin to observe a random sample of residents to ensure resident safety is maintained during transport in shower chairs.
- The Nursing Home Administrator arranged an ADHOC Quality Assurance Performance Improvement meeting in collaboration with the Medical Director to discuss the root cause analysis of the deficient practice.
- The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety.
Failure to Provide Assistive Devices Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide necessary assistive devices to prevent accidents for a resident who was at risk of falls. The resident, who was cognitively intact and required extensive assistance with bed mobility and transfers, fell out of bed while being assisted by a nursing assistant. The care plan for the resident included the use of a transfer/assist rail as an enabler for turning and repositioning in bed, but this intervention was not implemented at the time of the incident. During the incident, the nursing assistant was providing care and attempted to turn the resident to her left side. The resident typically used the side rail for support, but on this occasion, the rail was not raised, leading to the resident rolling out of bed and sustaining significant injuries, including a large laceration on her right lower leg and a partially avulsed toenail. The nursing assistant admitted to not reviewing the care plan prior to providing care and assumed the rails were in place as usual. The incident resulted in the resident being transported to the emergency room for evaluation and treatment. The resident returned to the facility with staples and sutures due to the injuries sustained. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the facility's expectation was for residents to be free from accidents, highlighting a failure in ensuring the proper use of assistive devices as per the resident's care plan.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's choice to receive showers as scheduled or requested, which is a violation of the resident's right to self-determination. The resident, who has moderate cognitive impairment and requires extensive staff assistance for bathing, expressed that he was not receiving showers on his designated days and times. The facility's records showed inconsistencies in the documentation of showers, with several entries made during third shift hours, which the Director of Nursing stated was not standard practice unless in extreme circumstances. Interviews with staff revealed conflicting accounts regarding the resident's shower refusals. Some staff members stated that the resident occasionally refused showers, while others indicated that he looked forward to them and rarely refused. Despite these claims, there was no documentation of any refusals in the resident's nursing notes, and the care plan did not address potential refusals of showers. The facility's documentation showed that the resident received an inconsistent number of showers each month, with some entries being identified as documentation errors. The discrepancies in shower records and the lack of proper documentation of refusals highlight the facility's failure to adhere to the resident's preferences and ensure accurate record-keeping, leading to the deficiency identified by the surveyors.
Resident-to-Resident Altercation Due to Wandering
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident struck another with a cane. The incident involved a resident with post-traumatic stress disorder, unspecified psychosis, insomnia, and major depressive disorder, who was cognitively intact and had no prior behaviors. This resident was startled when another resident, who had severe dementia and a history of wandering, entered their room. The startled resident reacted by striking the wandering resident multiple times with a cane. The wandering resident, who was severely cognitively impaired, was known to wander into other residents' rooms and had interventions in place to redirect them. On the day of the incident, the wandering resident entered the room of the other resident, leading to the altercation. Staff interviews revealed that the incident was unexpected as there had been no previous altercations between the residents, and both were generally considered pleasant. Following the incident, the wandering resident was found with bruising and was sent to the emergency room for evaluation. The resident who struck them was placed on one-to-one supervision and also sent for evaluation. The facility's staff, including nurses and social workers, were familiar with both residents and noted that the incident was unforeseen, as the resident who struck the other had never shown aggression before.
Failure to Report Abuse Allegations to APS
Penalty
Summary
The facility failed to report allegations of abuse to Adult Protective Services (APS) for three residents. In the first case, a resident alleged that a staff member took their earphones without permission. The facility became aware of the incident early in the morning, but APS was not notified until three days later. The initial report indicated that local law enforcement was notified, but there was no mention of APS notification until the investigation report was completed. In the second case, a resident alleged that a nurse grabbed their arm. The facility was aware of the incident the same day, and the alleged perpetrator was suspended, with law enforcement being notified. However, APS was not contacted, and the former Administrator stated she was unaware of the requirement to notify APS. In the third case, a resident-to-resident altercation occurred, and law enforcement was notified, but APS was not. The former Administrator did not report the incident to APS, believing the resident was safe and unaware of the requirement.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for assistance with activities of daily living. The resident, who was cognitively intact and had a history of stroke, compressed spinal cord, and contracture of the right elbow, was observed to have excessively long and unkempt fingernails, some of which appeared to have a fungal infection. Despite the resident's repeated requests for nail care, staff did not address the issue in a timely manner. Interviews with staff revealed a lack of communication and follow-through regarding the resident's nail care needs. A nurse aide reported the fungal condition to a nurse but did not mention the length of the nails, and the nurse did not recall receiving any report about the issue. The unit manager and the Director of Nursing were unaware of the resident's requests and the condition of the nails, indicating a breakdown in communication and oversight within the facility's care team.
Failure to Maintain Proper Oxygen Orders and Administration
Penalty
Summary
The facility failed to obtain physician orders for continuous oxygen for a resident with chronic obstructive pulmonary disease (COPD) and emphysema, and did not administer oxygen at the ordered rate for another resident. Resident #16, who was admitted with diagnoses of COPD, emphysema, shortness of breath, and chronic pain syndrome, was initially on hospice services with orders for continuous oxygen at 2 liters per minute (2L/M). However, after hospice services were discontinued, the orders for continuous oxygen were not maintained. Despite being cognitively intact and aware of her need for continuous oxygen, Resident #16 was noncompliant with wearing her oxygen as ordered and was known to adjust the flow rate. Interviews with nursing staff revealed that the oversight in maintaining the oxygen orders occurred when hospice services ended, and the Medical Director acknowledged the lack of orders. Resident #86, who was admitted with COPD and congestive heart failure (CHF), had a physician's order for oxygen at 4 liters via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set at 4.5 liters instead of the ordered 4 liters. Despite being cognitively intact and aware of her oxygen requirements, Resident #86 did not adjust the regulator herself. The discrepancy in the oxygen flow rate was confirmed by Nurse #1, who adjusted it to the correct setting. The Director of Nursing expressed that it was expected for oxygen to be delivered at the ordered rate.
Repeated Deficiencies in Resident Care and QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain effective procedures and monitor interventions following multiple surveys. During a recertification and complaint survey, the facility was cited for failing to provide nail care to one of seven residents dependent on staff for assistance with activities of daily living. In a previous complaint investigation, the facility failed to provide personal grooming for hair, face, and nails for one of three dependent residents. Additionally, during another recertification and complaint investigation, the facility failed to provide care for dependent residents in areas such as nail care, hair washing, bathing/showers, and incontinence care for four of nine residents reviewed for activities of daily living. These repeated deficiencies indicate a pattern of the facility's inability to sustain an effective QAPI program.
Failure to Revise Care Plan for Resident's ADL Abilities
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident in the area of staff assistance with dressing and bathing. The resident was admitted with a diagnosis of cerebral vascular accident with left-sided paralysis and had moderate cognitive impairment. The quarterly Minimum Data Set (MDS) indicated the resident required only set-up assistance with bathing and was independent with dressing. However, the resident's ADL care plan, last revised on 5/9/24, inaccurately stated that he required extensive staff assistance for dressing and bathing. Interviews with the resident and a nursing assistant revealed that the resident was able to dress himself and wash up independently, requiring only set-up assistance. The MDS Nurse acknowledged that the care plan should have been updated to reflect the resident's actual abilities, admitting it was an oversight. The facility administrator confirmed that the care plan should accurately reflect the resident's functional status.
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.
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What surveyors actually found near you
We read the 199 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near High Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westchester Manor At Providence Place | 1.8 mi | ★★★★★ | 0 | 0 |
| Maryfield Nursing Home | 3.5 mi | ★★★★★ | 1 | 0 |
| The Shannon Gray Rehabilitation & Recovery Center | 3.9 mi | ★★★★★ | 5 | 0 |
| Westwood Health And Rehabilitation | 4.5 mi | ★★★★★ | 18 | 0 |
| Magnolia Gardens Center For Nursing And Rehabilita | 5.8 mi | ★★★★★ | 3 | 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 August 2026) and official state health department websites.