Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadows Ridge Care Center during CMS and state inspections, most recent first.
A resident repeatedly requested her complete medical records from the Medical Records department and DON, receiving only partial records and no responses to follow-up emails. Despite facility policy requiring records to be provided within 48 hours, staff did not fulfill the requests or communicate with the resident, and could not explain the failure to comply.
A resident with multiple health conditions experienced an unwitnessed fall after call lights were not answered for an extended period. Nursing staff failed to document the incident, notify the physician, or monitor the resident post-fall, as required by facility policy. Interviews and record review confirmed the lack of documentation and follow-up.
A facility failed to monitor a resident's blood pressure and heart rate every six hours as ordered by the physician, leading to the resident being sent to the hospital for hypertension. Despite the care plan indicating a risk for cardiac distress, the staff only conducted weekly checks, contrary to the physician's orders.
A resident with depression and anxiety was financially exploited by a staff member who used the resident's EBT card for unauthorized purchases totaling $662.21, violating facility policies. The resident experienced emotional distress, and the incident highlighted a failure to adhere to financial abuse prevention and resident rights policies.
A facility failed to provide adequate personal hygiene care for a resident with multiple medical conditions, resulting in only two showers over nearly a month. There was no documentation of the resident's shower refusals, and the responsible party was not notified. Staff interviews revealed a lack of awareness and documentation regarding the refusals, contrary to the facility's policy.
The facility failed to follow food safety standards by storing expired marshmallows and leaving fruit juices on a resident's bedside table for two days. The Dietary Supervisor and Administrator acknowledged these lapses, which violated the facility's policies on food storage and tray collection.
A facility failed to replace oxygen tubing and supplies for a resident as per its policy, which mandates weekly replacement. The supplies were found to be nine months old, and staff acknowledged the oversight. The resident had conditions including cerebrovascular disease and dementia.
A resident experienced severe weight loss and worsening of a pressure ulcer, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within the required timeframe. The resident's care plan was not updated to reflect her current condition, potentially delaying necessary care. The DON and Administrator acknowledged the oversight during a record review.
A facility failed to timely implement RNA orders for a resident's ROM exercises, delaying the start of prescribed AAROM exercises for both lower and upper extremities. The resident, with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, began receiving exercises a week after the order was written. The RNA Supervisor and DON acknowledged the delay, which was against the facility's policy for timely treatment implementation.
A resident with multiple diagnoses, including a UTI, did not receive a prescribed dose of Ertapenem Sodium due to a delay in pharmacy delivery. The medication was available in the Emergency Kit, but staff failed to administer it, violating the facility's policy for timely medication administration.
A resident with protein-calorie malnutrition, dystonia, and epilepsy did not receive a physician-prescribed diet in a timely manner. The diet order, issued on August 8, 2024, was not implemented until August 26, 2024, despite facility policies requiring timely execution of physician orders. The DON confirmed the delay, which could have risked further nutritional and medical decline.
A CNA in an LTC facility failed to report redness on a resident's nose to the nursing staff, despite facility policies requiring such reporting. The resident had a history of malignant neoplasms and repeated falls. The CNA cited being busy and forgetting to report the condition, which was against the facility's job description and policy. The CNA was subsequently terminated.
A resident with multiple health issues and high risk for skin breakdown developed an open wound on the right pinkie finger. Despite a treatment order for daily wound care, the wound was observed without a dressing, and a treatment was missed. Staff interviews revealed a lack of communication and adherence to the care plan, with the DON and Administrator acknowledging the oversight.
A resident with a history of aggressive behavior was not monitored as required, leading to a physical altercation with another resident. The facility failed to document the resident's whereabouts as per the care plan and physician's orders, which increased the risk of further incidents. The DON acknowledged the lapse in following the facility's policy on resident-to-resident altercations.
The facility failed to follow its policy to ensure timely call light responses, resulting in two residents being left soiled and their activities of daily living not being met promptly. Interviews with CNAs and residents indicated that call lights took hours to be answered during the night shift, despite the facility's policies mandating timely responses and necessary care.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
A resident with a diagnosis of polyneuropathy and a BIMS score indicating cognitive intactness requested access to her complete medical records on multiple occasions via email to the Medical Records department and the Director of Nursing. The resident initially received only psychiatric notes after her first request, but subsequent requests for her full medical record, made on several dates, were not fulfilled. The resident also did not receive responses to her follow-up emails regarding these requests. Interviews and record reviews confirmed that the Medical Records staff received the resident's requests and were aware of the facility's policy requiring provision of records within 48 hours, excluding weekends and holidays. Despite this, the staff did not provide the requested records or respond to the resident's repeated communications. The Medical Records staff could not provide a reason for the lack of response or the failure to release the records, and the administrator acknowledged that the policy was not followed.
Failure to Document and Respond to Unwitnessed Fall
Penalty
Summary
The facility failed to follow appropriate procedures after an unwitnessed fall involving a resident with multiple medical conditions, including orthopedic aftercare, lower leg fracture, abnormal gait, diabetes, hyperlipidemia, kidney disease, hypertension, and syncope. The resident reported that call lights were not answered for extended periods, leading him to attempt to get up unassisted during the night, resulting in a fall. A nurse discovered the resident after the fall, but there was no documentation of the incident, no notification to the physician, and no evidence of post-fall monitoring or change of condition assessment. Interviews with nursing staff and review of the resident's records confirmed that the fall was not documented in the progress notes, and required notifications and monitoring were not completed. The Director of Nursing and other staff acknowledged that facility policy required documentation, physician notification, and monitoring after such incidents, but these actions were not taken. The facility was unable to provide any documentation that the required procedures were followed after the resident's fall.
Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications for one of the sampled residents, Resident 4. The licensed staff did not monitor Resident 4's blood pressure and heart rate every six hours as ordered by the resident's physician. This oversight was critical as Resident 4 had a history of hypertension, hemiplegia, type 2 diabetes mellitus, and end-stage renal disease, making them clinically compromised. The care plan for Resident 4 highlighted the risk for cardiac distress and required monitoring of vital signs to prevent unrecognized signs and symptoms of cardiac issues. Despite the physician's orders to administer Hydralazine as needed and monitor vital signs every six hours, the Medication Administration Record showed no recordings of blood pressure and heart rate from February 1 to February 17, except on February 18. The Licensed Vocational Nurse admitted to not checking the blood pressure every six hours, and the Director of Nursing confirmed that the staff was only conducting weekly blood pressure checks, contrary to the physician's orders. This failure resulted in Resident 4 being sent to the hospital for evaluation and treatment due to hypertension.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 4 is no longer in the facility and was discharged 2/18/2025. On 3/5/2025, the DON initiated an in-service to the licensed staff regarding medication administration guidelines and procedures, emphasizing monitoring blood pressure for residents on anti-hypertensive medications as ordered by the physician. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/5/2025, DON/Designee conducted an order and MAR review of all residents on anti-hypertensive medications to ensure all residents with such orders have BP monitoring as ordered by the physician. No additional discrepancies were noted with the same deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. The DON/designee will review new orders for anti-hypertensive medications weekly for 3 months to ensure all residents with orders have BP monitoring in place. How the facility plans to monitor its performance to make sure that solutions are sustained. Reporting and review of the above will occur monthly in QA Meeting with the QA Committee for 3 months.
Financial Exploitation of Resident by Staff Member
Penalty
Summary
The facility failed to protect a resident from financial exploitation by a staff member, leading to a deficiency. The incident involved a resident who was admitted with diagnoses including depression, anxiety, and colonostomy status. The resident voluntarily gave her EBT card and PIN to a staff member, Employee 1, with the condition that purchases should not exceed $600. However, Employee 1 copied the card details and used them to make unauthorized purchases totaling $662.21, violating the facility's policy against accepting money or gifts from residents. The facility's policies on financial abuse prevention and resident rights were not followed, as confirmed by the Administrator and Director of Nursing. The resident experienced emotional distress due to the financial abuse, and the social worker was unaware of the resident's possession of an EBT card. The facility's rules of conduct explicitly prohibit employees from borrowing money or accepting gifts from residents, which Employee 1 violated by using the resident's EBT card for personal gain.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to adhere to its policy regarding the provision of Activities of Daily Living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the facility did not provide adequate personal hygiene care for a resident, as evidenced by the lack of showers and insufficient documentation of shower refusals. The resident, who had multiple medical conditions including cerebral infarction, benign prostatic hyperplasia, neurogenic bladder, urinary tract infection, schizoaffective disorder, and hypertension, received only two showers and 22 bed baths over a period of nearly a month. There was no documentation of the resident's refusals to shower in the care plan or progress notes, and the responsible party was not notified of these refusals. Interviews with facility staff, including the Director of Nursing (DON) and the Director of Staff Development (DSD), revealed a lack of awareness and documentation regarding the resident's shower refusals. The DSD acknowledged that shower refusals should be documented and revisited, but was unsure why this was not done for the resident in question. The DON confirmed that there were no records of shower refusals and was unaware of the resident's refusals, which should have been documented as part of the resident's behavior. The facility's policy, revised in March 2018, mandates that residents unable to perform ADLs independently should receive necessary services to maintain personal hygiene, and any refusals should be documented and communicated to the resident's representative.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by two specific incidents. Firstly, during an inspection of the dry storage room, two unopened one-pound bags of mini marshmallows were found to be 54 days past their expiration date. The Dietary Supervisor acknowledged the oversight and confirmed that the facility's policy, which prohibits the storage of expired food items, was not followed. Secondly, in a resident's room, two cups of fruit juice were found on the bedside table, labeled with a date indicating they were two days old. The Licensed Vocational Nurse confirmed that these juices were from a meal tray and should not have been left overnight. The facility's policy requires that food trays be collected after each meal to minimize the risk of foodborne illness, which was not adhered to in this instance. The Administrator acknowledged the lapse in following the policy.
Failure to Replace Oxygen Supplies as Per Policy
Penalty
Summary
The facility failed to implement proper infection control prevention measures for a resident using oxygen therapy. Specifically, the oxygen tubing and related supplies for a resident were not replaced according to the facility's policy and procedure. The resident, who was admitted with diagnoses including cerebrovascular disease, dementia, and dysphagia, had oxygen supplies that were marked with a date nine months prior, indicating they had not been replaced as required. This oversight was observed during a room inspection, where the oxygen tubing and setup bag were found to be outdated. During an interview, a registered nurse acknowledged that the supplies should have been replaced weekly, as per the facility's policy, which mandates weekly replacement of oxygen tubing and related supplies. The night shift staff was responsible for this task, but it was not completed. The facility's administrator also confirmed that the staff failed to adhere to the oxygen administration policy, which required the weekly replacement of the supplies.
Failure to Complete SCSA for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant decline in condition. This resident, admitted with diagnoses including protein calorie malnutrition and an unstageable pressure ulcer in the sacral region, experienced severe weight loss and worsening of the pressure ulcer. The resident's weight decreased from 133 pounds to 116 pounds over three months, a 12.8% loss, which is considered severe. Additionally, the pressure ulcer increased in size and severity, indicating a significant decline in the resident's condition. Despite these changes, the facility did not conduct the required SCSA, which resulted in the resident's care plan not being updated to reflect her current status. The Director of Nursing (DON) and Administrator acknowledged the oversight during a review of the resident's records, admitting that the assessment completed was a Quarterly Assessment instead of the necessary SCSA. This failure to perform the appropriate assessment potentially delayed the implementation of necessary care and support for the resident.
Delay in Implementing RNA Orders for Resident's ROM Exercises
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), as the Restorative Nursing Assistant (RNA) orders for the resident were not carried out in a timely manner. The resident, who was admitted with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, had physician's orders for Active Assistive Range of Motion (AAROM) exercises for both lower and upper extremities. These orders were intended to be performed multiple times a week as tolerated. However, the resident did not begin receiving these exercises until a week after the initial order was written. During a review of the resident's RNA progress notes and an interview with the RNA Supervisor and the Director of Nursing (DON), it was acknowledged that the RNA orders were delayed. The facility's policy and procedure for physician orders, which requires timely implementation of treatment orders, was not followed. This delay in carrying out the RNA orders could have potentially led to a delay in preventing severe contractures of all extremities for the resident.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to administer medications in accordance with the prescriber's orders and facility policy for a resident who was prescribed an antibiotic for a urinary tract infection. The resident, who was admitted with diagnoses including protein-calorie malnutrition, dystonia, and epilepsy, was prescribed Ertapenem Sodium to be administered intramuscularly in the evening for 10 days. However, the Medication Administration Record indicated that the resident did not receive the prescribed dose on the second day of treatment. The nursing progress notes documented that the medication was not administered because it was awaiting delivery from the pharmacy. During a review of the incident, a registered nurse acknowledged that the medication was available in the Emergency Kit and should have been administered from there. The facility's policy, which requires medications to be administered in a safe and timely manner as prescribed, was not followed in this instance.
Delayed Implementation of Physician-Prescribed Diet
Penalty
Summary
The facility failed to ensure that a resident received a diet prescribed by their physician in a timely manner. The resident, who was admitted with diagnoses of protein-calorie malnutrition, dystonia, and epilepsy, had a diet order from their primary care physician dated August 8, 2024, which specified a small quarter-size chopped soft diet with thin liquids. However, there was no documented evidence that this diet order was written and carried out by the facility from August 8, 2024, through August 25, 2024. The diet order was only implemented on August 26, 2024, 18 days after the original order was received. During an interview and record review on October 4, 2024, the Director of Nursing acknowledged that the diet order was not carried out in a timely manner. The facility's policy requires that all physician orders be specific, complete, and supported by a diagnosis or condition, and the Registered Nurse is responsible for ensuring these orders are followed. This lapse in timely implementation of the diet order had the potential to place the resident at risk for further nutritional and medical decline.
CNA Fails to Report Skin Condition
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) demonstrated competency in skills and techniques for a resident, leading to a deficiency. The CNA noticed redness on the nose of a resident, who had been admitted with diagnoses of malignant neoplasms of the stomach and kidney, as well as a history of repeated falls. Despite observing the redness, the CNA did not report it to the licensed vocational nurse (LVN) or the registered nurse (RN), citing being busy and forgetting to inform the licensed staff. This inaction was contrary to the facility's job description for CNAs, which requires them to observe and report skin conditions. The LVN and RN were also interviewed, with the LVN assuming the redness was already identified due to the resident's behavior of hitting her face, and the RN stating he was not informed until later. The facility's policy and procedure on changes in a resident's condition or status, which mandates prompt notification of changes to the resident's medical condition, was not followed. The administrator confirmed that the CNA did not adhere to the job description or policy, leading to the CNA's termination.
Failure to Provide Wound Care for High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who developed an open wound on the right pinkie finger. The resident, who was admitted with multiple diagnoses including enterocolitis, mononeuropathy, muscle weakness, and protein-calorie malnutrition, was identified as high risk for skin breakdown. Despite a wound care order dated September 18, 2024, which specified daily treatment with Xeroform and foam dressing, the wound was observed without a dressing on September 24, 2024. The Treatment Administration Record for September 23, 2024, also indicated a missed wound treatment. During observations and interviews, it was noted that the resident's wound was exposed, with blood smearing between the fingers, and no dressing was applied as ordered. The CNA and LVN acknowledged the absence of the dressing, with the LVN unsure why the treatment was not administered. The Director of Nursing and the Administrator confirmed the oversight, recognizing the resident's high risk for skin breakdown and the need for staff education. The facility's policies on wound care and pressure injury prevention were reviewed, highlighting the requirement for proper wound management and reporting.
Failure to Monitor Resident with Aggressive Behavior
Penalty
Summary
The facility failed to ensure proper supervision and monitoring of a resident who had a history of aggressive behavior. This deficiency was identified when the resident, who had been diagnosed with bipolar disorder, Alzheimer's disease, and anxiety disorder, was involved in a physical altercation with another resident. The resident's care plan and physician's orders required monitoring of the resident's whereabouts every two hours to prevent such incidents. However, the facility did not adhere to these orders, as evidenced by missing documentation of the resident's whereabouts on multiple occasions. The Director of Nursing (DON) confirmed that the monitoring was not conducted as required and acknowledged that the facility's policy on resident-to-resident altercations was not followed. The policy mandated documentation of all interventions and their effectiveness, which was not done in this case. The lack of adherence to the care plan and physician's orders increased the risk of further altercations, potentially leading to injuries and bodily harm.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to follow its policy and procedure to ensure call lights were answered in a timely manner, which resulted in two residents being left soiled and their activities of daily living not being met promptly. Resident 1, who has diagnoses including osteoarthritis, spinal stenosis, polyneuropathy, hemiplegia, and depression, reported that call lights took two hours to be answered at night, leaving them soiled and fearful of developing urinary tract infections. Similarly, Resident 2, diagnosed with multiple sclerosis, paraplegia, obesity, hyperlipidemia, hypotension, and overactive bladder, stated that call lights took hours to be answered, resulting in them sitting on soaking wet waterproof pads for extended periods. Interviews with CNAs corroborated these complaints, indicating that residents often complained about long wait times for call light responses during the night shift. The facility's policy and procedure documents, including those for Activities of Daily Living, Answering the Call Light, and Resident Rights, were reviewed and found to mandate timely responses to residents' needs and the provision of necessary care to maintain good hygiene and dignity. Despite these policies, the administrator claimed to be unaware of any complaints regarding delayed call light responses. This discrepancy between policy and practice highlights a significant lapse in the facility's adherence to its own standards, potentially compromising resident safety and well-being.
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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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Nursing homes near Colton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Canyons Post-acute | 0.6 mi | — | 7 | 0 |
| Grand Terrace Health Care Center | 1 mi | — | 5 | 0 |
| Heritage Gardens Health Care Center | 2.9 mi | — | 0 | 0 |
| Loma Linda Post Acute | 2.9 mi | — | 0 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 3.8 mi | — | 10 | 0 |
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