Encore at West Meadow L.L.C.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Jun 16, 2026.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. Correction date, as CMS recorded it: Nov 17, 2025.

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Rule F0553. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Honor the resident’s right to be treated with respect and dignity and to retain and use personal possessions.

Rule F0557. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Rule F0561. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Ensure the transfer/discharge meets the resident’s needs/preferences and that the resident is prepared for a safe transfer/discharge.

Rule F0627. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Rule F0745. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide or obtain dental services for each resident.

Rule F0791. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Rule F0838. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Rule F0843. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Rule F0844. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Implement a program that monitors antibiotic use.

Rule F0881. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Rule F0909. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Rule F0941. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Rule F0944. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide training in compliance and ethics.

Rule F0946. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Rule F0949. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Rule F0837. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Feb 26, 2026.

Ensure that residents are free from significant medication errors.

Rule F0760. G: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 8, 2025.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 28, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 28, 2025.

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Rule F0553. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Keep residents’ personal and medical records private and confidential.

Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

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.

Rule F0625. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

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.

Rule F0758. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Oct 7, 2024.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 7, 2024.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 7, 2024.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Rule F0949. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 7, 2024.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Rule F0944. B: no actual harm, potential for minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 7, 2024.