Encore at West Meadow L.L.C.

In the surveyor’s words

From the most serious findings on record at Encore at West Meadow L.L.C., in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 25, 2026

  Based on observation, interview, and record review, it was determined that one (R1) of three residents sampled did not receive adequate supervision and assistive devices to prevent elopement, as R1 is a newly admitted resident identified as an elopement risk. This failure resulted in R1 eloping from the facility to a busy road between approximately 5:00 PM and 5:20 PM without supervision or intervention. An Immediate Jeopardy was identified to the facility on 6/25/26 at 10:00 AM and was determined to be past noncompliance as of 6/16/26.Findings include:Review of R1's clinical record revealed:6/12/26- R1 was admitted to the facility for short-term rehab with diagnoses that included, but were not limited to, traumatic subarachnoid hemorrhage (a bump or blow to the head that caused bleeding… […]

• Immediate jeopardy, isolatedF689Jan 12, 2026

  Based on observation, interview and record review, the facility failed to provide adequate supervision for R22, an independent resident who told multiple staff prior to the incident that he wanted to go home. On 11/10/25, R22 self-ambulated his wheelchair from the healthcare area to the independent living front lobby entrance and exited the building without staff knowledge. R22 continued down a main traffic road where the speed limit was 45 miles per hour for 0.3 of a mile and then called 911 where police officers responded. As a result of the inadequate supervision, R22's elopement from 4:50 AM to 5:21 AM had the potential to have a serious outcome, injury or death. An immediate jeopardy past non-compliance was called on 1/8/26 at 9:57 AM. […]

• Immediate jeopardy, isolatedF689Aug 28, 2024

  Based on interview, record review and review of other facility documentation it was determined that for three (R1, R2 and R3) out of three residents reviewed for wandering and elopement the facility failed to provide adequate supervision to prevent elopements. R1 eloped on two occasions 8/16/24 and 8/18/24. On 8/16/24, R1 was seen in the parking lot. On 8/18/24, R1 was seen outside of the building, near the fire lane of the facility turn-in and a busy roadway. Additionally, R2 eloped from the facility on 8/17/24 and was found outside of the building at the edge of the curb on the rounded driveway. On 7/11/24, R3 was seen exiting the facility unattended by a facility visitor who immediately reported R3's elopement to staff. […]

• Actual harm, isolatedF760Oct 29, 2025

  Based on record review and interview, it was determined that for one (R1) out of four residents reviewed for pharmacy services, the facility failed to ensure R1 was free of a significant medication error. This failure resulted in a harm in which R1 seized and was transferred to the hospital on 8/7/25 with benzodiazepine withdrawal from missing four doses of lorazepam. Based on a review of the facility's corrective actions taken and completed on 8/8/25 at 11:20 PM, it was determined that this incident was past non-compliance. Findings include:8/5/25 11:59 AM - R1's [Hospital] Discharge summary documented, . Medications at discharge. lorazepam 2 mg (milligrams) oral tablet, 1 tablet by mouth 2 times a day. Please contact PCP (primary care provider) for refill. […]

• Actual harm, isolatedF690Sep 16, 2022

  Based on interview, record review, review of the facility's policy, and review of the hospital records, it was determined that for one (R1) out of three (3) resident's sampled for urinary incontinence reviews, the facility failed to ensure that R1 received appropriate treatment and services to prevent urinary tract infections (UTIs). R1 had a known history of recurrent UTIs and was readmitted to the facility on [DATE]. From 7/7/22 through 7/13/22, the facility failed to identify a significant change of condition, a potential worsening of signs and symptoms (s/s) of UTI (lower abdominal pain and inability to urinate), they failed to immediately consult with the Attending Physician and failed to closely assess and monitor R1's condition. […]