Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Park Meadows Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that staff did not consistently follow physician orders for several residents, including an RN repeatedly holding ordered insulin without required physician notification, and an LPN crushing and administering a delayed-release medication without clarifying its appropriateness. Wound care orders for daily and three-times-weekly dressing changes were not carried out as prescribed, with dressings left unchanged for days and staff unable to account for missed treatments. A resident ordered to wear an AFO during transfers and when out of bed was frequently observed without it, while documentation of application was incomplete and CNAs reported not consistently applying or keeping the device on. Another resident on G-tube feeding had feeding and water setups used beyond the ordered timeframe, and an LPN restarted tube feedings and administered medications without checking gastric residuals as required by the physician order.
The facility failed to maintain accurate, resident-centered comprehensive care plans aligned with current assessments and communication needs. One resident with a nephrostomy was incorrectly care planned for a colostomy, while another resident continued to be care planned as a smoker despite no longer smoking or leaving bed to smoke. A third resident, assessed as mostly independent and able to perform personal hygiene such as shaving, still had a care plan stating dependence for all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required interpreter services had no communication focus in the care plan, even though staff and clinical documentation acknowledged the language barrier and use of translation methods.
A resident with orders for multiple medications, including probiotics, vitamin C, Eliquis, Famotidine, and insulin (Glargine and Apidra), had several scheduled doses in one month with no corresponding entries on the MAR. Because the resident disliked certain LPNs, nurses informally split responsibilities so that one nurse administered medications while another documented them, leading to missed documentation when the documenting LPNs forgot or were distracted. This practice conflicted with facility policy requiring the staff providing care to record medications administered, resulting in incomplete and inaccurate clinical records for the resident.
The facility was found to have an unsanitary environment across all hallways, with trash and debris present and no housekeeping staff observed during the inspection. Residents expressed dissatisfaction with the housekeeping services, and the Administrator confirmed the lack of adherence to the cleaning schedule.
A resident with a mechanical soft diet order was served a hotdog, which did not meet dietary restrictions, leading to a finding of neglect. Despite being informed by an RN, the LPN did not remove the food item, and a CNA cut the hotdog for the resident. The resident had a complex medical history, including dysphagia, increasing the risk of aspiration. Staff interviews revealed a lack of adherence to diet verification procedures, contributing to the incident.
A resident with a mechanical soft diet order was inappropriately served a hotdog, despite staff being aware of the dietary restriction. The LPN retrieved the hotdog without verifying the resident's diet, and neither the LPN nor the RN removed the food after realizing the error. The CNA cut the hotdog, but it still did not meet the mechanical soft diet requirements. This led to Immediate Jeopardy due to the facility's failure to provide a safe environment and adequate supervision.
A resident with a mechanical soft diet was improperly served a hotdog, despite staff being aware of the dietary restriction. The LPN failed to verify the diet, and the RN did not remove the food after identifying the error. The resident's complex medical history, including dysphagia, increased the risk of harm, leading to a determination of Immediate Jeopardy.
A resident with specific dietary needs was given a hotdog by an LPN without verifying the diet order, despite an RN's warning. The resident's diet required a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture. The staff failed to remove the inappropriate food item, leading to a determination of neglectful behavior and Immediate Jeopardy due to the facility's failure to implement policies and procedures for therapeutic diets.
The facility failed to serve food at an appetizing temperature, as evidenced by resident complaints and a test tray observation. Residents reported receiving cold food, and a test tray showed food temperatures below the optimal level. The facility's policy requires food to be served at a safe and appetizing temperature, which was not adhered to, resulting in the deficiency.
The facility failed to maintain a clean and secure environment in two shower rooms and the memory care unit. A resident reported mold in the shower rooms, which was confirmed by observations of black substances on the ceilings. In the memory care unit, a door had a gap due to a plywood repair, exposing the interior to the outside. The Maintenance Director was unaware of these issues, despite a policy for maintenance work orders.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as only one fall mat was placed instead of the required two. Additionally, another resident's care plan lacked focus on incontinence care, despite documented needs and staff observations. These deficiencies were contrary to the facility's policy on comprehensive assessments and care plans.
A resident did not receive blood pressure medication according to the physician's order, which specified holding the medication if the SBP was greater than 110. The medication was administered multiple times when the SBP exceeded this parameter. Interviews with the DON and Medical Director confirmed the error, but no negative impact on the resident's health was observed.
Two residents in an LTC facility did not receive dietary services as prescribed by their physicians. One resident, with Alzheimer's and other health issues, was not given the required frozen nutritional treat with meals, despite a physician's order. Another resident, with diabetes and renal disease, received insufficient meal portions, contrary to the prescribed double protein diet. Both cases highlight a failure to adhere to the facility's dietary policies, as confirmed by registered dietitians.
A facility failed to provide timely laboratory services for a resident, missing scheduled tests for Hemoglobin A1c and Depakote levels as ordered by the physician. The oversight was confirmed by the DON, who noted that the tests were conducted only after the issue was identified. The facility's policy requires timely diagnostic services, which was not followed in this instance.
A facility failed to accurately document the provision of a frozen nutritional treat for a resident with a physician's order due to weight loss. Observations showed the resident did not receive the treat during meals, despite the MAR indicating otherwise. Interviews with the DON and an LPN revealed expectations for accurate documentation and meal checks, yet discrepancies were noted.
The facility failed to ensure proper infection control practices, as observed in the actions of a CNA and an LPN who did not sanitize equipment or perform hand hygiene during medication administration. Additionally, a clean linen cart was improperly used to store personal items, violating the facility's infection control policies.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Failure to Follow Physician Orders for Medications, Wound Care, Orthotic Use, and Enteral Feeding
Penalty
Summary
The deficiency involves multiple failures by nursing and therapy staff to follow physician orders for medications, treatments, devices, and enteral nutrition. One resident with diabetes had an order for daily Insulin Glargine with instructions to notify the physician if blood sugar was less than 70 mg/dL. Review of the MAR showed that an RN repeatedly held the insulin on numerous dates when blood sugars were between 60 and 117 mg/dL, including several instances where no blood sugar was documented at all, and the RN stated she misread the order and did not recall notifying the physician. Another resident had an order for a delayed-release oral medication, Zunveyl 10 mg twice daily, with a general order allowing medications to be crushed unless contraindicated. An LPN crushed the delayed-release tablet and administered it without first clarifying with the provider or pharmacy, later acknowledging that the medication was delayed release and that she should have obtained clarification. The deficiency also includes failures to follow wound care orders for residents with skin conditions. One resident who had a dermatology biopsy on the left side of the neck had a physician order for daily wound care on the day shift for seven days, including washing with soap and water, applying petroleum jelly, and covering with a nonstick bandage. Observations on two consecutive days showed the same dressing dated several days earlier still in place, and the resident reported that the dressing had not been changed. Nursing staff interviewed either did not recall the dressing date, stated they did not see dressing change orders, or could not recall what happened on the ordered wound care day. Another resident with a right knee wound from a fall at home had an order for wound care three times weekly on the day shift (Tuesday, Thursday, Saturday). The wound care nurse stated she worked on the relevant Saturday but did not perform the ordered dressing change because the resident was up, and the DON stated staff should follow physician orders and perform wound care as ordered. Additional deficiencies occurred in the implementation of therapy-related and enteral feeding orders. One resident with an order for a right ankle orthosis (AFO) to be applied during transfers and when out of bed was repeatedly observed in a wheelchair and in bed without the AFO, while the device was stored in the closet. The task list showed documentation of AFO application for several days early in the month but no entries on later dates when the resident was observed without the device. Therapy and nursing staff described that restorative aides were to apply the AFO, but a restorative CNA reported they were not applying it and were instead working with a hand splint, and a CNA stated she sometimes removed the AFO when the resident was sitting because she thought he did not like to wear it. Another resident receiving enteral nutrition via G-tube had a physician order for Jevity 1.5 at a specified rate and schedule, with an order to check tube residual prior to feeding, medications, and flushes, and to hold feeding and notify the physician if residual was 100 mL or more. Observations showed the feeding bottle and attached water bag in use beyond 24 hours, and an LPN stated she believed the setup was good for 24 hours and based changes on what was left in the bottle. When restarting the feeding, the LPN set the pump according to the order but did not check for residual, and she confirmed she did not check residuals prior to medication administration or initiation of feeding, despite the physician order and facility policy requiring verification of tube placement and residual volumes.
Failure to Maintain Accurate, Resident-Centered Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain accurate, resident-centered comprehensive care plans consistent with residents’ assessed needs and conditions. For one resident with hemiplegia, overactive bladder, and a nephrostomy catheter, the care plan incorrectly documented a focus on an artificial bowel opening (ostomy/colostomy) with related bowel-output interventions, even though the resident did not have a colostomy. The MDS LPN and the DON both confirmed that the resident had a nephrostomy, not a colostomy, indicating the care plan did not reflect the resident’s actual medical status. Another resident with pulmonary fibrosis, morbid obesity, malnutrition, feeding difficulties, malignant neoplasm of the glottis, dysphagia, and GERD had a care plan focus indicating the resident was a smoker/tobacco user, initiated and last revised several years earlier. Interviews with the resident, an LPN, and the DON confirmed that the resident no longer smoked, did not get out of bed or go outside to smoke, and had not had a recent smoking evaluation because the resident was no longer an active smoker. Despite this, the care plan still identified the resident as a smoker, showing it had not been updated to reflect the resident’s current status. A third resident with hemiplegia, seizures, dementia with behavioral disturbance, and restlessness/agitation had a care plan focus stating the resident had self-care deficits and required assistance with all ADLs, including dressing, grooming, and bathing. However, interviews with nursing staff and the resident indicated the resident was mostly independent, steady, moved independently, and shaved independently after obtaining a razor from CNAs. The MDS assessment completed the prior month documented the resident as independent for personal hygiene, but the care plan, last updated many months earlier, still showed a need for assistance with all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required an interpreter had no communication focus in the care plan, despite documentation in a skin exam note that a translator app and the resident’s son were used for communication, and staff interviews confirming the resident primarily spoke Spanish. The MDS LPN and DON acknowledged that care plans were not up to date and that a communication focus needed to be added, demonstrating that the care plans did not incorporate identified communication needs or align with the facility’s policy requiring culturally competent care planning.
Incomplete Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for one resident related to medication administration. Physician orders for this resident included Acidophilus 100 mg capsules twice daily, Ascorbic Acid 500 mg tablets twice daily, Eliquis 5 mg twice daily for unspecified atrial flutter, Famotidine 20 mg twice daily for GERD, Insulin Glargine 35 units subcutaneously twice daily for diabetes in a dialysis patient, and Apidra SoloStar 8 units subcutaneously before meals for type 2 diabetes with complications. Review of the resident’s MAR for December showed missing documentation entries for multiple scheduled doses of these medications, including Acidophilus, Ascorbic Acid, Eliquis, Famotidine, Insulin Glargine, and Apidra at specified afternoon/evening administration times. Interviews with nursing staff revealed that the resident did not like certain LPNs, leading to an informal practice where one nurse would administer the medications while another nurse was responsible for documenting them on the MAR. One LPN stated she gave all of the resident’s medications on a specific date and expected another LPN to document them, while that LPN acknowledged she was supposed to document the medications but must have forgotten. Another LPN reported that, due to the resident’s verbal abuse, another nurse administered the medications while she pulled the insulin and verified with the other nurse that the medications were given, but she believed she became distracted and failed to sign off on the MAR. The facility’s policy on Charting and Documentation required that medications administered and services performed be recorded in the resident’s clinical record by the staff providing care, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain an orderly and sanitary environment across all four hallways (100, 200, 300, and 400), as observed during a tour on March 29, 2025. Trash and debris were noted in these areas, with no housekeeping carts present during the inspection. Specific observations included significant debris near the exit to the smoking patio on the 100 hallway, consisting of leaves, grass, and small pieces of trash. Interviews with residents revealed dissatisfaction with the housekeeping services, with one resident describing it as a 'joke.' Further observations confirmed the continued presence of trash and debris, and a large, uncovered cart filled with soiled linens and trash was noted, emitting a foul odor. Additionally, a brownish dried liquid was observed on the wall in the 100 hallway. The Administrator confirmed the unsanitary conditions and acknowledged that the housekeeping staff did not work on the morning of the inspection. The Administrator stated that housekeeping personnel are expected to follow a checklist for cleaning rooms and common areas, but this schedule was not adhered to. The absence of housekeeping staff and the failure to follow the cleaning checklist contributed to the unclean environment observed during the survey.
Failure to Adhere to Dietary Restrictions Leads to Neglect
Penalty
Summary
The facility failed to protect a resident from neglect by not adhering to the prescribed dietary requirements. A resident, who had a physician's order for a mechanical soft diet, was served a hotdog and hotdog bun, which did not comply with the dietary restrictions. Despite being informed by a Registered Nurse (RN) that the resident should not have a hotdog, the Licensed Practical Nurse (LPN) did not remove the food item. The resident attempted to consume the hotdog, and a Certified Nursing Assistant (CNA) further facilitated this by cutting the hotdog in half, although this did not meet the mechanical soft diet requirements. The resident involved had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, malnutrition, and dysphagia, which increased the risk of aspiration and choking. The Speech Therapy evaluation indicated the resident was on a mechanical soft diet due to decreased oral function and risk of aspiration. Despite these clear dietary restrictions, the staff failed to verify the resident's diet before serving the hotdog, and the error was not corrected even after it was identified. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding diet verification and neglect prevention. The LPN admitted to freezing and not removing the plate due to the presence of a surveyor, while the RN assumed the LPN would take corrective action. The Cook and Food Service Director acknowledged that the procedure for verifying diet orders was not followed, contributing to the incident. The facility's failure to implement its policies and procedures for neglect led to the determination of Immediate Jeopardy.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Nursing Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Inappropriate Diet Served to Resident with Mechanical Soft Diet Order
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was served an inappropriate therapeutic diet. The incident involved a resident who had a physician's order for a mechanical soft diet due to conditions including dysphagia and risk for aspiration. Despite this, the resident was served a hotdog, which was not suitable for their dietary needs. The error was identified by a registered nurse, but neither the nurse nor the licensed practical nurse who served the meal took action to remove the inappropriate food item. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and other health issues, was observed in the dining room requesting an alternative food item. The licensed practical nurse retrieved a hotdog from the kitchen without verifying the resident's dietary restrictions. Although the registered nurse informed the licensed practical nurse that the resident should not have a hotdog, the food was not removed, and the resident attempted to consume it. A certified nursing assistant later cut the hotdog in half, but this did not meet the requirements of a mechanical soft diet. Interviews with staff revealed a lack of adherence to procedures for verifying and serving appropriate diets. The cook did not verify the resident's diet due to the absence of a meal ticket, and the licensed practical nurse did not follow the protocol of checking the diet before serving the food. The registered nurse, overwhelmed with other tasks, assumed the licensed practical nurse would correct the mistake but did not intervene directly. This series of actions and inactions led to the determination of Immediate Jeopardy, highlighting the facility's failure to provide adequate supervision and a safe environment for the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Dietary Policies Leads to Immediate Jeopardy
Penalty
Summary
The facility administration failed to effectively manage resources to ensure the highest practicable physical well-being of each resident, specifically by not implementing policies and procedures related to neglect and therapeutic diets. A resident with a physician's order for a mechanical soft diet was served a hotdog, which was not in compliance with their dietary needs. Despite being informed by a registered nurse that the resident should not have a hotdog, the licensed practical nurse did not remove the food item, and a certified nursing assistant further facilitated the resident's consumption by cutting the hotdog in half. The resident in question had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, and dysphagia, which increased their risk for aspiration and choking. The resident had been evaluated by a speech therapist and was on a mechanical soft diet due to these risks. However, the staff involved failed to verify the resident's dietary needs before serving the hotdog, and even after recognizing the error, they did not take corrective action to remove the inappropriate food item. Interviews with staff revealed a lack of adherence to established procedures for verifying and serving diets. The licensed practical nurse did not verify the resident's diet with the kitchen staff, and the cook did not follow the procedure of checking the diet ticket or verifying the diet with the nurse. The registered nurse, although aware of the dietary error, did not intervene effectively to prevent the resident from consuming the inappropriate food. This series of actions and inactions led to a determination of Immediate Jeopardy due to the potential harm posed to the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Therapeutic Diet Policies
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a deficiency in implementing policies and procedures for neglect and therapeutic diets. On October 15, 2024, a resident requested an alternative food item from a Licensed Practical Nurse (LPN) in the dining room. The LPN provided a hotdog and hotdog bun without verifying the resident's diet in the kitchen. A Registered Nurse (RN) identified the error, stating that the resident was not supposed to have a hotdog, but neither the RN nor the LPN removed the food item from the resident. The resident, who had a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture and thin consistency, was observed picking up the hotdog and placing it in his mouth, although he did not chew or swallow it. A Certified Nursing Assistant (CNA) then cut the hotdog in half, allowing the resident to attempt to consume it again. The resident's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, and diabetes, which necessitated adherence to a specific diet. The facility's failure to act upon the identified dietary error and remove the inappropriate food item was determined to be neglectful behavior. The incident was classified as Immediate Jeopardy due to the systemic breakdown in implementing the facility's policies and procedures, which was not addressed through the QAPI process. The Nursing Home Administrator acknowledged the failure to act and recognized the neglectful nature of the staff's inaction.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Deficiency in Serving Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as evidenced by multiple resident complaints and a test tray observation. Resident #105 reported that breakfast trays often arrived late, resulting in cold food. Similarly, Resident #109 also complained about receiving cold food. During a test tray observation, food temperatures were measured using a calibrated thermistor digital thermometer. The food, which included ravioli with meat sauce and Italian green beans, was placed on a tray and in an insulated cart at 12:10 PM and left the kitchen at 12:14 PM. By the time the last resident began eating at 12:42 PM, the food temperatures were recorded at 109 degrees Fahrenheit for the ravioli and 89.6 degrees Fahrenheit for the green beans, both below the optimal serving temperature. The Registered Dietitian confirmed that the optimal food temperature when served should be above 110 degrees Fahrenheit, and the kitchen ensures food is above 135 degrees when initially placed on plates. The facility's policy, last reviewed on January 31, 2024, mandates that food and drink be nutritious, palatable, attractive, and served at a safe and appetizing temperature. Despite these guidelines, the facility did not adhere to its policy, resulting in the deficiency noted during the survey.
Facility Fails to Maintain Clean and Secure Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and comfortable environment in two shower rooms and the memory care unit. During an interview, a resident reported that the shower rooms were consistently dirty and moldy. Observations confirmed the presence of a black substance in a circular pattern on the ceiling over the shower area and brown discoloration on the ceiling leading to the shower area in the 100 Hall Shower Room. Additionally, a line of black substance spots was observed on the ceiling over the area leading into the shower in the 500 Hall Shower Room. The Maintenance Director was unaware of these issues. In the memory care unit, a hallway exterior exit door had a large piece of plywood attached where glass should have been, with a 2-inch gap between the plywood and the metal door frame at the bottom, exposing the interior to the outside. During an observation with the Maintenance Director and Housekeeper Supervisors, it was confirmed that the duct tape used to secure the plywood had come off, leaving a gap. The Maintenance Director acknowledged he was unaware of the gap and the tape's failure. The facility's policy on maintenance work orders was reviewed, indicating a system for requesting and completing maintenance, but it appears this system was not effectively implemented in these instances.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as being at risk for falls. Observations on multiple occasions revealed that the resident had only one fall mat placed on the left side of the bed, despite a physician's order and care plan specifying that fall mats should be placed on both sides. This discrepancy was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the expectation to follow physician orders and care plans. Additionally, the facility did not develop a comprehensive care plan for another resident who was occasionally incontinent of bowel and bladder. The resident's care plan lacked a focus on incontinence care, despite the resident's condition being documented in the Minimum Data Set and physician orders for medication related to urinary retention. Interviews with staff indicated that the resident often refused to be cleaned up, yet this issue was not addressed in the care plan, contrary to the facility's policy on comprehensive assessments and care plans.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to administer blood pressure medication as prescribed by the physician for a resident. The physician's order for the resident, dated March 6, 2024, specified that Midodrine HCl Tablet 10 mg should be given every 8 hours for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. However, the Medication Administration Record (MAR) for October 2024 showed that the medication was administered multiple times when the resident's SBP was above the specified parameter, including readings of 116, 122, 126, 124, 114, 127, 125, 123, and 112. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the medication was given outside the prescribed parameters. The DON acknowledged the error but noted that the resident had recently attended a cardiology appointment and was reportedly fine, with no negative impact observed. The Medical Director also reviewed the situation and revised the parameters, stating that the resident's health was stable and monitored, with no adverse effects from the medication administration error.
Failure to Provide Prescribed Dietary Services
Penalty
Summary
The facility failed to provide dietary services as prescribed by the physician for two residents, leading to deficiencies in their nutritional care. Resident #43, who has a history of Alzheimer's dementia, feeding difficulties, and other health issues, was observed multiple times without receiving the prescribed frozen nutritional treat with meals, despite a physician's order for it due to weight loss. The resident's care plan indicated a risk for alteration in nutrition and hydration, yet the prescribed dietary interventions were not consistently followed, as evidenced by the absence of the nutritional treat during meal observations. Resident #128, who has a diagnosis of type 2 diabetes mellitus, end-stage renal disease, and other health conditions, was also not provided with meals that met the prescribed dietary requirements. The resident's physician order specified a renal controlled carbohydrate diet with double meat/protein with meals, but observations revealed insufficient meal portions, such as a half peanut butter and jelly sandwich for lunch, which was deemed inadequate by the registered dietitian. The resident experienced significant weight loss, further indicating that the dietary needs were not being met as prescribed. The facility's policy and procedure for providing diets to meet the needs of each resident were not adhered to, as both residents did not receive meals consistent with their physician's orders. The registered dietitians acknowledged the inadequacy of the meals provided, highlighting a failure in the facility's food and nutrition services to ensure that residents' nutritional and hydration needs were met according to their individual care plans and physician orders.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, specifically for the monitoring of Hemoglobin A1c and Depakote levels, as ordered by the physician. The physician's order, dated June 18, 2024, required these tests to be conducted every three months. However, a review of the resident's medical record revealed no documentation of the laboratory tests being performed in September 2024. During an interview, the Director of Nursing confirmed that the lab work was not completed as scheduled and stated that the blood was drawn on the morning of October 17, 2024, after the oversight was discovered. The facility's policy, last reviewed on January 31, 2024, mandates the provision of timely laboratory, radiology, and diagnostic services when ordered by a physician or other qualified healthcare professionals. This policy was not adhered to in the case of the resident, leading to a deficiency in meeting the resident's healthcare needs.
Failure to Accurately Document Nutritional Supplementation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident identified as having a physician's order for a frozen nutritional treat with meals due to weight loss. Observations over several days revealed that the resident did not receive the frozen nutritional treat during meals, despite the physician's order. Specifically, during meal observations on multiple occasions, the resident was noted to be eating various meals without the prescribed frozen nutritional treat. The Medication Administration Record (MAR) inaccurately documented that the resident received the frozen nutritional treat at specified times, which was contradicted by direct observations. Interviews with the Director of Nursing and a Licensed Practical Nurse highlighted expectations for accurate documentation and meal tray checks, yet discrepancies persisted. The facility's policy on charting and documentation mandates that services provided to residents be accurately recorded, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and the handling of medical equipment and clean linens. During observations, a Certified Nursing Assistant (CNA) did not sanitize a vital sign machine between residents, using it on multiple residents without cleaning. The CNA acknowledged the oversight, stating that disinfecting wipes were not available on their cart at the time. Additionally, a Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after administering medications to residents, even after donning and doffing gloves. The LPN admitted to not using hand sanitizer between residents, which is against the facility's hand hygiene policy. Furthermore, the facility did not maintain a clean storage environment for linens. A clean laundry cart was found with a bottle of coke and a bag of chips among the clean sheets, which was confirmed by the Housekeeping Supervisor as inappropriate. The facility's policy on handling linens to prevent infection was not adhered to, as evidenced by the improper storage of personal items on the clean linen cart.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hammock At The University Of Florida Inc | 1.1 mi | — | 0 | 0 |
| Gainesville Health And Rehabilitation | 1.5 mi | — | 3 | 0 |
| Plaza Health And Rehab | 1.5 mi | — | 9 | 0 |
| Parklands Care Center And Rehab | 2.6 mi | — | 0 | 0 |
| Palm Garden Of Gainesville | 2.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.