Facility profile · CCN 085021
Encore At West Meadow
39 federal citations on record , including 1 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $16,448.
Record summary
Federal record · Q1 202639
Total citations
29
Last 3 years
2
Actual harm+
1
Federal penalties
$16,448
Total fines
4
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
39 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Oct 29, 2025 | F760 | Ensure that residents are free from significant medication errors. | G | Complaint |
| Oct 29, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Oct 29, 2025 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Complaint |
| Nov 26, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Nov 26, 2024 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Nov 26, 2024 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Nov 26, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Nov 26, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Nov 26, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Nov 26, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Nov 26, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Nov 26, 2024 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Nov 26, 2024 | F625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D | Standard |
| Nov 26, 2024 | F583 | Keep residents' personal and medical records private and confidential. | D | Standard |
| Nov 26, 2024 | F553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | Standard |
| Aug 28, 2024 | F949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E | Complaint |
| Aug 28, 2024 | F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | B | Complaint |
| Aug 28, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint |
| Aug 28, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Aug 28, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E | Complaint |
| Oct 19, 2023 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Oct 19, 2023 | F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Complaint |
| Oct 19, 2023 | F730 | Observe each nurse aide's job performance and give regular training. | D | Complaint |
| Oct 19, 2023 | F728 | Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | D | Complaint |
| Oct 19, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Complaint |
| Oct 19, 2023 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Complaint |
| Oct 19, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint |
| Oct 19, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Oct 19, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Apr 14, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Apr 14, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | E | Complaint |
| Mar 31, 2021 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Mar 31, 2021 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Standard |
| Mar 31, 2021 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Standard |
| Mar 31, 2021 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Mar 31, 2021 | F585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | E | Standard |
| Mar 31, 2021 | F577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | E | Standard |
| Mar 31, 2021 | F574 | The resident has the right to receive notices in a format and a language he or she understands. | E | Standard |
| Mar 31, 2021 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
Federal enforcement history
Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $16,448 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Aug 28, 2024 | Fine | $16,448 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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