The Meadows on University

    1315 S University Dr, Fargo, ND 58103
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Excellent rehab care, compassionate staff

    I'm very pleased with my mother's stay - the CNAs and nursing staff are professional and caring, therapy (Tiffany and team) drove real rehab progress, and administration is responsive. The facility is very clean, housekeeping excellent, meals are well-prepared with gluten-free options, and activities create a warm, welcoming atmosphere. Friendly staff across departments (Marsha and Holly especially helpful) made visits pleasant - I'm grateful to have this rehab-focused place in Fargo.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.61·(70)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.8
    • Staff

      3.3
    • Meals

      3.4
    • Amenities

      1.8
    • Value

      1.0

    Pros

    • Strong physical and occupational therapy services
    • Compassionate and hardworking nursing and aide staff
    • Improved food quality and varied meal options
    • Active activities program including faith-based services
    • Welcoming front-office and administrative support
    • Housekeeping and generally clean common areas
    • Supportive rehab-focused environment for short-term stays
    • Allowance for room personalization
    • Effective hospice and end-of-life coordination

    Cons

    • Inconsistent staffing levels and responsiveness
    • Gaps in medication and oxygen-administration processes
    • Communication and family-notification inconsistencies
    • Inconsistent meal-service timing and quality
    • Older infrastructure with small shared rooms and need for updates
    • Sanitation and odor concerns in some common areas
    • Language and communication skill variability among clinical staff
    • Inconsistent activity programming and resident engagement
    • Inconsistent billing and pricing practices
    • Security and behavior-management process gaps
    • Operational instability during management transitions

    Summary of reviews

    The available reviews present a mixed picture of The Meadows on University, with a clear pattern of polarized experiences. Many families and residents describe strong rehabilitative services, kind and hardworking direct-care staff, and improvements under new leadership. At the same time, other accounts raise substantial operational concerns that prospective residents and families should evaluate during a tour and intake conversation.

    Care quality shows notable strengths and vulnerabilities. Rehabilitation and therapy services (physical and occupational therapy) are frequently praised and appear to be a core competency; several reviewers characterized the environment as rehab-focused and effective for short-term recovery. Nursing staff and nurse aides are often described as compassionate and attentive, and hospice coordination receives positive mention. However, there are recurring accounts of delayed assistance, inconsistent responsiveness to personal-care needs, and problems with medication and oxygen administration processes. These reports point to gaps in clinical workflows and staffing consistency rather than isolated praise or complaint—areas to probe further, particularly around staffing ratios, clinical protocols, and emergency response procedures.

    Staffing and communication are uneven. Many reviewers compliment specific caregivers and departments for kindness and responsiveness, and some families report an open-door management approach and improved transparency. Conversely, other reviewers describe poor communication with families, lack of timely notifications, variability in staff communication skills (including language barriers), and concerns about the tone of staff interactions. Management turnover and transitional leadership were mentioned; some observers reported constructive changes (improved food, resident input initiatives) while others described ongoing instability and administrative friction, including inconsistent billing and pricing practices.

    Dining and activities present a similar pattern of improvement paired with inconsistency. Several reviews note improved food quality and better-tasting meals after recent changes, and activity offerings include faith-based services, social events, fitness training, and special events. Yet other accounts describe late meal service, variable meal quality, and periods with little resident engagement. Activity programming appears to be meaningful when staffed and supported, but engagement may be inconsistent depending on scheduling and staffing.

    The physical plant is characterized as older and in need of updates. Rooms—especially semi-private two-bed rooms—are generally described as small. Housekeeping and cleanliness receive praise in many comments, though some reviewers raised odor concerns in certain hallways and noted a need for facility refresh. Security and behavior-management processes are another area of concern: there are mentions of incidents involving aggressive behavior and perceived gaps in security practices, suggesting prospective families should ask about behavioral protocols and safety measures.

    Notable patterns for decision-making: experiences are polarized, with both consistently positive remarks about therapy and many individual staff members and serious concerns about operational reliability (staffing consistency, clinical protocols, family communication, billing). Some reviews reference regulatory citations and hospital transfers; these should prompt verification of the facility’s current compliance status. For families considering The Meadows on University, recommended next steps include an on-site visit, meetings with nursing leadership to review staffing ratios and clinical protocols (including medication and oxygen administration), asking for recent inspection/citation history, sampling meals at mealtime, observing activities, and speaking with current residents or family members about communication and billing practices. The facility may be a good fit for those prioritizing strong therapy services and compassionate individual caregivers, but families should confirm that the facility’s operational controls meet their expectations for safety, responsiveness, and transparency.

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    Medicare Ratings

    2·/ 5
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of The Meadows on University

    The Meadows on University is located at 1315 S University Dr, Fargo, ND, 58103.

    About The Meadows on University

    The Meadows on University sits in Fargo and serves Cass County and Region V, and you'll find it offers both short-term rehab and long-term care, taking in people on Medicaid, Medicare, or private insurance, and you'll notice it's a state-certified skilled nursing facility with beds for up to 131 residents-though, on average, about 53 people live there day by day. Folks here can get physical, occupational, and speech therapy, especially if they need extra help after surgery, and they can expect a team of licensed nurses and therapists on hand 24 hours a day for care, pain management, medications, and just plain hygiene-so there's always someone to help, day or night, with skilled nursing services. Residents get a mix of rehabilitation, short-term, long-term, outpatient, and respite care, plus the staff includes a named administrator, Josh Kelly, a Director of Nursing called Eliza Messerschmidt, and a Social Worker named Genn Bervig, so you know who's in charge and who to go to for help or questions. People staying here get care plans that fit their individual needs, whether it's help managing memory problems or trouble with daily activities, and while they do accept people with Alzheimer's or dementia, they don't have a special unit just for that. You'll also see the place has regular social activities to keep folks engaged and connected, which helps the community feel welcoming and warm, and people can learn strategies for coping with changes, all while connecting with others facing similar situations. Meals, bathing, managing medicine, and therapy are all handled by licensed professionals, and the therapy team works with local hospitals and clinics, so people can transition from one level of care to another if needed. Now, you should know this place keeps up with Medicare and Medicaid guidelines, is managed by Eduro Healthcare LLC, and has a nurse staffing level of about 3.75 hours per resident each day, but it's had its fair share of inspection issues, like 47 documented deficiencies, including for food temperature and quality, infection control, and some concerns over continence care and catheter use, with four infection-related issues noted recently, and a nurse turnover rate of 53.6% noted, so there's been some staff changes. Still, people seem to get the basics-rehab, regular health checks, and a safe environment-without any big promises, and services focus on keeping folks as comfortable as possible for as long as they stay.

    People often ask...

    The Meadows on University offers assisted living, memory care, and skilled nursing.

    There are 39 photos of The Meadows on University on Mirador.

    The full address for this community is 1315 S University Dr, Fargo, ND 58103.

    No, The Meadows on University does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In North Dakota, Health & Human Services' Health Facilities unit licenses care facilities and publishes the health and life-safety deficiencies found during inspections.

    License numberSNF-the-meadows-on-university-fka-manorcare-health-services-fargo
    Facility typeSkilled Nursing Facility

    Inspection Reports

    56

    Reports

    17

    Type A Citations

    0

    Type B Citations

    0

    Complaints

    16

    Years

    14 Apr 2026Inspection
    Investigated the complaint and found no deficiencies.
    30 Dec 2025Inspection
    Found that a baseline care plan was not developed for a new admission, failing to reflect essential ADL needs. Audits identified additional incomplete 48-hour care plans for other residents.
    • 42 CFR 483.21Baseline Care Plan
    04 Dec 2025Inspection
    Investigated infection control noted deficiencies with hand hygiene and isolation precautions for a resident with C. difficile during an unannounced survey.
    • 42 CFR 483.80Infection Control
    13 Nov 2025Inspection
    Investigated a complaint and found no deficiencies.
    28 Apr 2025Life Safety
    Identified that three sprinkler system gauges dated 03/06/2020 had not been replaced or calibrated within the last five years, potentially compromising system reliability.
    • NFPA 25; NFPA 25 4.1.4.1, 5.3.2.1, 5.3.2.2; NFPA 25 9.7.6, 4.6.12Gauges maintenance and testing of automatic sprinkler system
    09 Apr 2025Inspection
    Investigated found deficiencies across multiple areas including resident rights, dignity during care, call systems, assessments, ADL care, skin integrity, nutrition, food safety, and infection control.
    • CFR 483.10Resident Rights/Exercise of Rights
    • CFR 483.10(e)Reasonable Accommodations Needs/Preferences
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25Quality of Care
    • CFR 483.25(g)Nutrition/Hydration Status Maintenance
    • CFR 483.60(i)Food Procurement, Store/Prepare/Serve-Sanitary
    • CFR 483.80Infection Prevention & Control
    31 Jul 2024Inspection
    Found no deficiencies. The complaint investigation concluded compliance with regulatory requirements.
    20 Feb 2024Life Safety
    Found electrical safety deficiencies, including lack of GFCI protection on several outlets in a workshop area and insufficient clearance around electrical cabinets.
    • NFPA 70, 210.8Ground-fault protection not provided where required
    • NFPA 70, 110.26; NFPA 70, 119.26(B)Working space around electrical cabinets not maintained
    08 Feb 2024Inspection
    Identified multiple deficiencies in medication management, including unclear insulin administration timing, PRN psychotropic use without end dates, medication administration errors, and improper medication labeling.
    • CFR(s): 483.21(b)(3)(i) §483.21(b)(3)Comprehensive Care Plans
    • CFR 483.45(c)(3)(e)(1)-(5)Psychotropic Drugs
    • CFR 483.45(f)(1)Medication Errors
    • CFR 483.45(g)(h)(1)(2) and 483.45(h)Labeling of Drugs and Biologicals / Storage of Drugs and Biologicals
    21 Aug 2023Life Safety
    Identified multiple life-safety and electrical-system deficiencies, including egress locking, fire protection, electrical safety, and generator maintenance. The findings indicate violations of several standards.
    • 7.2.1.5.3Egress Doors
    • NFPA 72 14.4.2.2Fire Alarm System - Testing and Maintenance
    • NFPA 25; 9.7.5, 9.7.7, 9.7.8Sprinkler System - Maintenance and Testing
    • NFPA 70; 210.8; 210.8(B)Utilities - Gas and Electric
    • 19.7.1.4 through 19.7.1.7Fire Drills
    • NFPA 99; NFPA 110Electrical Systems - Essential Electric System
    09 Aug 2023Inspection
    Found deficiencies in maintaining a safe, clean environment for residents on oxygen and in the accuracy of assessments.
    • 42 CFR 483.10(i)Safe Environment
    • 42 CFR 483.20(g)Accuracy of Assessments
    17 Nov 2022Inspection
    Found deficiencies in pain management due to unavailable pain medications and in infection prevention and control due to insulin pens being shared between residents.
    • CFR 483.25(k)Pain Management
    • CFR 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
    11 Oct 2022Inspection
    Identified several deficiencies, including failure to maintain resident dignity during toileting, improper medication administration, inadequate continence care, and unsafe medication storage.
    • CFR 483.10Resident Rights
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans
    • CFR 483.25(e)(1)-(3)Incontinence
    • CFR 483.45(g)-(h)Labeling/Storage of Drugs and Biologicals
    03 Aug 2022Inspection
    Investigated a complaint and found multiple deficiencies across resident care areas, including call light response, grievances handling, investigations, care planning, bathing, toileting, nutrition, oxygen use, staff competency, and transfer agreements.
    • Type ACFR 483.10(e)(3)Reasonable accommodations/Preferences
    • Type ACFR 483.10(f)(5)-(7)Resident/Family Groups and Response
    • Type ACFR 483.12(c)(1)(4)Reporting of Alleged Violations
    • Type ACFR 483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    • Type ACFR 483.21(b)(2)Care Plan Timing and Revision
    • Type ACFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • Type ACFR 483.25(b)Skin Integrity - Pressure Ulcers
    • Type ACFR 483.25(e)Incontinence, Toileting, and Urinal Care
    • Type ACFR 483.25(g)Nutrition/Hydration Status Maintenance
    • Type ACFR 483.25(i)Respiratory Care and Suctioning
    • Type ACFR 483.35(a)(3)-(4)(c)Competent Nursing Staff
    • Type ACFR 483.35(g)(1)-(4)Posted Nurse Staffing Information
    • Type ACFR 483.70(j)(1)-(2)Transfer Agreement
    • Type ACFR 483.95(c)(1)-(3)Abuse, Neglect, Exploitation Training
    07 Jun 2022Inspection
    Found no deficiencies during the revisit.
    27 Apr 2022Life Safety
    Found deficiencies related to NFPA 96 cooking facilities requirements and fire alarm system testing/maintenance. Manual pull station height was above 48 inches and fire alarm devices were not tested annually.
    • NFPA 96; NFPA 101; 18.3.2.5.1-18.3.2.5.4; 19.3.2.5.1-19.3.2.5.5; 9.2.3Cooking Facilities
    • NFPA 70; NFPA 72; NFPA 101; 9.6.1.3; 9.6.1.5; 19.3.4.1Fire Alarm System - Testing and Maintenance
    21 Apr 2022Inspection
    Investigated a complaint and identified multiple deficiencies across resident rights, environment, care, medication, nutrition, safety, and infection control, indicating noncompliance with federal requirements.
    • CFR §483.10(g)(17)-(18)Medicaid/Medicare Coverage/Liability
    • CFR §483.10(i)(1)-(7)Safe/Clean/Comfortable/Homelike Environment
    • CFR §483.12Freedom from Abuse and Neglect
    • CFR §483.21(b)Comprehensive Care Plans
    • CFR §483.21(b)(3)Services Provided Meet Professional Standards
    • CFR §483.25Quality of Care
    • CFR §483.25(b)Nutrition/Hydration Status Maintenance
    • CFR §483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    • CFR §483.25(g)Nutrition/Hydration Status Maintenance
    • CFR §483.25(i)Respiratory/Tracheostomy Care and Suctioning
    • CFR §483.30Resident’s Care Supervised by a Physician
    • CFR §483.35Competent Nursing Staff
    • CFR §483.45Pharmacy Services/Procedures
    • CFR §483.45(h)Label/Store Drugs and Biologicals
    • CFR §483.60Menus Meet Resident Needs/Prep in Advance/Followed
    • CFR §483.60(d)(4)-(5)Resident Allergies, Preferences, Substitutes
    • CFR §483.75(g)(2)QAPI/QAA Improvement Activities
    • CFR §483.80Infection Prevention & Control
    • CFR §483.80(i)COVID-19 Vaccination of Facility Staff
    12 Oct 2021Inspection
    Found no deficiencies; compliance with COVID-19 preparedness and infection control was confirmed.
    13 Sept 2021Inspection
    Found inadequate turning and repositioning for a dependent resident, with missing documentation and care planning.
    • CFR 483.24(a)(2)ADL care provided for dependent residents
    25 Feb 2021Inspection
    An investigation found multiple deficiencies involving resident rights, care quality, safety, nutrition, dialysis, medication administration, infection control, and staff oversight. Numerous instances showed failures to follow orders, protect dignity, ensure proper monitoring, and maintain proper procedures.
    • CFR 483.10Resident Rights
    • CFR 483.10(c)(6)(8)(g)(12)(i)-(v)Right to Refuse/Discontinue Treatment; Advance Directives
    • CFR 483.25Quality of Care
    • CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
    • CFR 483.25(g)Nutrition/Hydration Status
    • CFR 483.25(i)Respiratory/Tracheostomy Care and Suctioning
    • CFR 483.25(l)Dialysis
    • CFR 483.35RN Coverage
    • CFR 483.45Pharmacy Services
    • CFR 483.45(f)Medication Error Rates
    • CFR 483.45(g)(h)Labeling and Storage of Drugs
    • CFR 483.80Infection Prevention & Control
    15 Dec 2020Inspection
    Found no deficiencies. The survey determined compliance with infection control requirements and noted one COVID-19 positive resident at the time.
    24 Nov 2020Inspection
    Found no deficiencies related to infection control; compliance with required practices was verified.
    02 Nov 2020Life Safety
    Identified deficiencies in fire alarm system testing/maintenance and in the emergency generator's load testing and annual maintenance.
    • NFPA 70; NFPA 72; NFPA 101Fire Alarm System - Testing and Maintenance
    • NFPA 99; NFPA 110; NFPA 111; NFPA 70Electrical Systems - Essential Electric System
    29 Apr 2020Inspection
    Found no deficiencies; infection control practices for COVID-19 were compliant.
    16 Mar 2020Inspection
    Confirmed compliance with COVID-19 infection control requirements and CDC/CMS recommendations.
    18 Jun 2019Inspection
    The regulator found multiple deficiencies after an on-site revisit, including failure to promptly notify about changes in resident condition, inadequate abuse investigations, incomplete care plans, lapses in insulin administration standards, and delayed UTI assessment and treatment.
    • 42 CFR §483.10(g)(14)-(15)Notify of Changes
    • 42 CFR §483.12(b)Abuse Investigation and Reporting
    • 42 CFR §483.21(b)(2)-(iii)Care Plan Timing and Revision
    • 42 CFR §483.21(b)(3)(i)Services Provided Meet Professional Standards
    • 42 CFR §483.25(e)Incontinence and UTIs
    16 May 2019Inspection
    The survey found multiple deficiencies across resident care, including inadequate communication of rights, delayed/incorrect medical notifications, improper MDS coding, insufficient care planning, inconsistent wound and dialysis care, staffing issues, dietary problems, infection control lapses, and inadequate dental and ADL support.
    • CFR 483.10(g)(4) (i)-(vi); CFR 483.10(g)(15)Required Notices and Contact Information
    • CFR 483.10(g)(14); CFR 483.10(g)(15)Notify of Changes; (Change in conditions/room/rights)
    • CFR 483.20(f)(1)-(4)Encoding/Transmitting Resident Assessments (MDS submissions)
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)(1)Develop/Implement Comprehensive Care Plan
    • CFR 483.21(b)(2)Care Plan Timing and Revision
    • CFR 483.21(b)(3)Services Provided Meet Professional Standards
    • CFR 483.25(b)Quality of Care; Skin/Pressure Ulcers
    • CFR 483.25(d)Accidents; Supervision/Devices
    • CFR 483.25(e)Bowel/Bladder Incontinence
    • CFR 483.25(i)Respiratory Care
    • CFR 483.25(l)Dialysis
    • CFR 483.35(a)(1)-(2)Sufficient Nursing Staff
    • CFR 483.55(a)Routine/Emergency Dental Services
    • CFR 483.60(c)Menus
    • CFR 483.60(d)Nutritive Value/Palatable/Proper Temperature
    • CFR 483.80Infection Prevention & Control
    17 Apr 2019Life Safety
    Identified multiple life-safety deficiencies across emergency lighting, exit signage, hazardous areas, fire alarm testing, sprinkler system installation, portable extinguishers, electrical outlets, and emergency generator testing.
    • NFPA 101, 7.9.3.1.1Emergency Lighting
    • NFPA 101, 19.2.10.1; 7.10.8.3.1; 7.10.8.3.2Exit Signage
    • NFPA 101, 19.3.2.1; 19.3.5.9Hazardous Areas - Enclosure
    • NFPA 70; NFPA 72; NFPA 70, 14.1.1; NFPA 72, 14.4.2.2Fire Alarm System - Testing and Maintenance
    • NFPA 13; NFPA 13 8.3.2; 19.3.5.1–19.3.5.5; 9.7; 9.7.1.1(1)Sprinkler System - Installation
    • NFPA 10, 7.2.1.1; 7.2.1.2Portable Fire Extinguishers
    • NFPA 70; NFPA 210.8; 210.8(B)(1); 210.8(B)(2); 210.8(B)(5)Utilities - Gas and Electric
    • NFPA 99 6.4.4.1.1.4; NFPA 110 8.4.1–8.4.2.3; NFPA 111 6.4.4; NFPA 70 700.10Electrical Systems - Essential Electric System
    06 Dec 2018Inspection
    Found multiple deficiencies in resident care including delayed call-light responses, incomplete care plans, inadequate bathing assistance, poor skin care, nutritional management problems, unmanaged pain, and illegible insulin labeling.
    • CFR 483.10(f)(5)-(7)Resident rights - Groups and family groups
    • CFR 483.21(b)(2)(i)-(iii)Comprehensive Care Plans
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25Quality of care
    • CFR 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • CFR 483.25(k)Pain Management
    • CFR 483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
    28 Jun 2018Inspection
    Identified multiple deficiencies across resident rights, clinical planning, medication administration, nutrition, dialysis care, infection control, and related areas.
    • CFR 483.10(g)(6)-(9)Right to Forms of Communication w/ Privacy
    • CFR 483.20(e)(1)-(2)Coordination of PASARR and Assessments
    • CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
    • CFR 483.21(b)(3)Services Provided Meet Professional Standards
    • CFR 483.25(b)Skin Integrity - Pressure Ulcers
    • CFR 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
    • CFR 483.25(l)Dialysis
    • CFR 483.45(d)Drug Regimen is Free from Unnecessary Drugs
    • CFR 483.60(d)Nutritive Value/Appear, Palatable/Proper Temperature
    • CFR 483.60(f)Frequency of Meals/Snacks at Bedtime
    • CFR 483.80(a)-(f)Infection Prevention & Control
    25 Apr 2018Life Safety
    Identified multiple life safety deficiencies, including obstructed exit discharge, hazardous-area enclosure failures, non-latching corridor doors, improper smoke detector placement, and unsecured oxygen cylinders.
    • NFPA 101 18.2.7, 19.2.7Exit Discharge
    • NFPA 101 4.6.12.2; 8.7.1; 19.3.5.9; 19.3.2.1Hazardous Areas - Enclosure
    • NFPA 72; 19.3.4.5.2; 19.3.4.5.1; 9.6.2.10.1.1Smoke Detection
    • NFPA 101 19.3.6.3.5Corridor - Doors
    • NFPA 99 11.6.2.3Gas Equipment - Cylinder and Container Storage
    10 May 2017Inspection
    Found multiple deficiencies in privacy, personal care, feeding, wound care, infection control, and food sanitation, indicating several resident safety and dignity concerns.
    • 483.10(h)(1)(3)(i); 483.70(i)(2)Personal privacy/confidentiality of records
    • 483.24; 483.25(k)(l)Provide care/services for highest well being
    • 483.24(a)(2)ADL care provided for dependent residents
    • 483.25(b)(1)Treatment/Services to prevent/heal pressure sores
    • 483.25(g)(4)(5)NG feeding and restored eating skills
    • 483.25(b)(2)(f)(g)(5)(h)(i)(j)Treatment/Care for special needs
    • 483.60(i)(1)-(3)Food procurement, storage, preparation, sanitation
    • 483.80(a)(1)(2)(4)(e)(f)Infection control and linens
    01 Mar 2017Life Safety
    Identified multiple life-safety deficiencies across emergency lighting, cooking-area systems, fire alarms, smoke detection, sprinklers, fire drills, and emergency power testing.
    • NFPA 101, Emergency Lighting (7.9.3)Emergency Lighting
    • NFPA 96, 19.3.2.5.10Cooking Facilities
    • NFPA 70, NFPA 72; 9.6.1.5Fire Alarm System - Testing and Maintenance
    • NFPA 72, 2010 edition; 17.7.6.3.2; A.17.7.4.1Smoke Detection
    • NFPA 13; NFPA 25Sprinkler System - Maintenance and Testing
    • NFPA 101, Fire Drills; 19.7.1.2; 18.7.1.4-18.7.1.7Fire Drills
    • NFPA 110Electrical Systems - Essential Electric System
    30 Jun 2016Inspection
    Investigated findings identified multiple deficiencies in resident care, medication management, infection control, and sanitation with potential risk to residents.
    • 483.20(k)(3)(i)SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
    • 483.25PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    • 483.25(l)DRUG REGIMEN IS FREE FROM UNECESSARY DRUGS
    • 483.25(m)(1)FREE OF MEDICATION ERROR RATES OF 5% OR MORE
    • 483.35(i)FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
    • 483.60(b), (d), (e)DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS
    14 Jun 2016Life Safety
    Found exit access not readily available because two doors open outward into the exit corridor and protrude more than seven inches when opened.
    • NFPA 101 Life Safety Code, 7.2.1.4.4Exit access not readily available; outward-opening doors projecting into exit corridor
    20 Apr 2016Inspection
    Investigated a complaint about call light response times. Found failures to listen to and act on grievances from residents and families.
    • 483.15(c)(6)Listen/Act on Group Grievance/Recommendation
    24 Feb 2016Inspection
    Identified multiple deficiencies: missing documentation of CAAs in MDS, inaccurate MDS coding, inadequate constipation and pressure ulcer care, lapses in infection control, and missing governing policies related to MDS processes.
    • 483.20(b)(1)Comprehensive Assessments
    • 483.20(g)-(j)Assessment Accuracy/Coordination/Certified
    • 483.25Provide Care/SERVICES for Highest Well Being
    • 483.25(c)Treatment/Services to Prevent/Heal Pressure Sores
    • 483.65Infection Control, Prevent Spread, Linens
    • 483.75(d)(1)-(2)Governing Body/Policies/Appoint Admin
    09 Jul 2015Inspection
    Investigated allegations of deficiencies and found ongoing failures in housekeeping and interior maintenance, with related issues in resident care practices.
    • Housekeeping and maintenance deficiencies
    14 May 2015Inspection
    Investigated skin alteration documentation and found deficiencies in recording and evaluating skin changes and bruises, including missing measurements and descriptions.
    • Continued From page 3 - management of actual and potential skin alterations; skin alteration documentation
    26 Feb 2015Inspection
    Investigated a complaint alleging inadequate care for constipation; two residents did not receive proper bowel management.
    • Care planning and provision of care to manage constipation
    17 Feb 2015Life Safety
    Identified deficiencies regarding smoke detector maintenance and testing, and sprinkler and generator system maintenance and testing.
    • Type ANFPA 101; NFPA 72; NFPA 25Smoke detector maintenance and testing deficiencies
    • Type ANFPA 25; NFPA 99; NFPA 72Sprinkler and smoke detector testing/compliance
    • Type ANFPA 99; NFPA 25Generator maintenance/testing
    17 Sept 2014Inspection
    Investigated a neglect incident and deficiencies related to resident safety and documentation; multiple care-planning and reporting issues were found.
    • Continued From page 3
    • Continued From page 4
    • Continued From page 9
    22 May 2014Inspection
    Found deficiencies related to residents' rights information and several care practices, including hydration and supervision, with failures to inform residents about services and costs and to provide proper physician contact information.
    • 42 CFR 483.10Resident rights and information about services and Medicaid eligibility
    • Resident information and physician contact
    • Supervision and hydration of residents
    26 Mar 2014Life Safety
    Investigated preventive maintenance documentation for the emergency generator transfer switch and found missing records for three of four quarters in 2013.
    • NFPA 110Preventive maintenance documentation for emergency generator transfer switch
    12 Feb 2014Inspection
    An investigation identified deficiencies in medication management and resident information sharing, including failures to prevent medication errors and to notify families about changes in resident conditions.
    • Significant medication errors not prevented; inadequate medication management
    09 Jul 2013Inspection
    Identified deficiencies regarding CPAP machine orders and monitoring. The facility failed to verify physician orders for CPAP machines and did not adequately document or monitor their use.
    • CPAP machine orders not verified; monitoring and documentation
    • Physician order for Resident #3's CPAP machine not obtained; pressure setting not documented
    08 May 2013Inspection
    Investigated deficiencies found related to resident privacy and the handling of medications and transfers. Found failures to protect privacy, determine residents' ability to self-administer medications, and notify residents or families about transfers or discharges.
    • Personal privacy/Confidentiality of Records
    • Self-administration of medications
    • Notice of transfer/discharge
    17 Apr 2013Life Safety
    Found that the fire-extinguishing system for commercial cooking operations was not inspected and serviced at least every six months, with record gaps between February 2012 and March 2013.
    • NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking OperationsInspection/servicing of fire-extinguishing systems in commercial cooking operations
    07 Jun 2012Inspection
    Investigated multiple deficiencies related to resident dignity and respect, accommodation of individual needs, and provision of care for residents' well-being.
    • 483.15(a)(1)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.15(e)(1)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
    • 483.25PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    06 Mar 2012Life Safety
    Concluded compliance with NFPA 101 Life Safety Code.
    09 Feb 2012Inspection
    Investigated deficiencies in care planning and documentation related to dehydration and constipation risk; the care plans and accompanying notes did not adequately address the resident's needs.
    • Continued From page 2 chronic constipation
    25 Jan 2012Inspection
    Investigated and found deficiencies in residents' grooming and personal care due to inadequate staff assistance; residents were observed with unkempt hair and poor grooming.
    • Grooming and personal hygiene
    21 Jul 2011Inspection
    The provider had multiple deficiencies involving resident activities, care planning, and documentation, indicating gaps in resident care and supervision. Several entries show failures to timely report investigations and to maintain adequate activity and daily living support for residents.
    • 483.13(c)(1)(ii)-(iii), (c)(2)-(4)Investigation/Report Allegations
    • 483.15(f)(1)Activities/Quality of Life
    • 483.10(b)ADL care provided for dependent residents
    • 483.10(b)ADL care provided for dependent residents
    13 Apr 2011Life Safety
    Found no deficiencies. The survey determined the facility was in compliance with NFPA 101 Life Safety Code.
    17 Jun 2010Inspection
    Investigated a complaint and found deficiencies in residents' dignity and independence, privacy during care, and infection control practices.
    • 483.15(a) DIGNITY AND RESPECT OF INDIVIDUALITYIndependence in daily decisions
    • 483.25(d) NO CATHETER, PREVENT UTI, RESTORE BLADDERProvision of privacy during care
    • 483.65 INFECTION CONTROL, PREVENT SPREAD, LINENSInfection control program
    16 Mar 2010Life Safety
    Identified multiple life-safety deficiencies related to smoke barriers, sprinkler system maintenance, and exit access/egress.
    • NFPA 101 Life Safety Code StandardSmoke barriers and sprinkler system standards
    • NFPA 101 Life Safety Code StandardExit doors/egress obstruction
    • NFPA 13; NFPA 25Sprinkler installation and maintenance
    • NFPA 101 Life Safety Code StandardExit access and egress

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