Avalon Care Center - Portland
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 12640 Se Bush, Portland, Oregon 97236
- CMS Provider Number
- 38E173
- Inspections on file
- 22
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avalon Care Center - Portland during CMS and state inspections, most recent first.
The facility failed to provide written transfer notices and written bed-hold policy information to three residents or their representatives at the time of hospital transfer. One resident with UTIs and sepsis and another with chronic heart failure, both responsible for their own decisions, were transferred without documented written notice or bed-hold information. A third resident with peripheral vascular disease, whose daughter was the responsible party, was transferred twice without documentation that the representative was notified. An LPN reported not documenting which documents were sent and that no written transfer notices were available, another LPN was unaware of the requirement to provide bed-hold or transfer notices, and the DNS could not find any related documentation and was unaware written transfer notices were required, while the administrator acknowledged such notices and bed-hold information were supposed to be provided.
A resident with Parkinson’s disease and anxiety, who was cognitively intact and care planned to be involved in daily decisions, repeatedly told staff and administration that they did not want a specific CNA providing their care. Despite the facility’s policy supporting resident self-determination and choice of health care providers, staffing records and observations showed that this CNA continued to be regularly assigned to the resident and provided care over multiple days. Several staff, including CNAs, social services, the staffing coordinator/HR, and the DNS, acknowledged awareness of the resident’s ongoing complaints and preference, but assignments were not changed, with leadership citing staffing challenges.
A resident with peripheral vascular disease was transferred to the hospital on multiple occasions, but the responsible party listed as the emergency contact was not notified, contrary to the facility’s Notification of Changes of Condition Policy. Nursing staff reported that their usual practice was to notify the emergency contact or responsible party before or immediately after a transfer and to document this in the clinical record, yet no such documentation existed for these transfers. Facility leadership later confirmed that the resident’s representative had not been notified and that nursing staff were not consistently contacting resident representatives regarding hospital transfers.
A resident with severe cognitive impairment, a history of sexual assault trauma, and a care plan noting preference for female staff was sexually abused by another cognitively impaired resident who had alcohol-induced persisting dementia, high-risk heterosexual behavior, and a documented history of sexual behaviors toward female residents. The second resident’s care plan required supervision around female residents, redirection of sexual behaviors, and intermittent 1:1 supervision after incidents, yet clinical records showed multiple prior sexually inappropriate incidents without evidence that 1:1 supervision was implemented. Staff reported that this resident was not to be alone with female residents, but the staffing coordinator observed the resident in a common area with a hand under the other resident’s shirt, fondling the breast while the victim tried to push the hands away, with no other staff present.
A resident with a history of cerebral infarction and depression was not properly assessed for the use of a power wheelchair, despite documented goals and improvements in fine motor and visual skills. Therapy sessions focused on related skills, but no direct evaluation with the power wheelchair occurred, and the resident's request for increased independence and socialization was not addressed through appropriate assessment.
Two residents with mental health diagnoses did not receive the required PASARR screenings. One resident with schizophrenia and anxiety did not have a PASARR II completed despite indications it was needed, and another resident with bipolar disorder and PTSD did not have a PASARR I screening on record. Staff confirmed these omissions during the survey.
A resident with dementia and PTSD, who had severe cognitive impairment, was not provided with activities aligned to their documented preferences, such as pet visits, listening to preferred music, group participation, or outdoor time. Despite staff and family confirming these interests, the care plan lacked these details, and the resident was observed sitting alone without engagement or inclusion in ongoing activities.
A resident with a right leg amputation who required two-person mechanical lift transfers was assisted by only one CNA without the lift, resulting in a fall. The CNA relied on the resident's statement about their transfer needs, but the care plan still required a mechanical lift and two-person assistance, which was not followed.
A resident with a history of UTIs was prescribed Bactrim for prophylaxis and later received cefuroxime, resulting in duplicate antibiotic therapy without documented review or rationale. Staff recognized the issue and attempted to clarify with the PCP, but no response was received and no justification for the dual therapy was documented, contrary to the facility's antibiotic stewardship policy.
A resident sustained second-degree burns due to the facility's failure to enforce its smoking policy. The policy required staff management of smoking materials, but residents were allowed to possess and use them independently. This led to an incident where a resident was injured while refilling another resident's lighter. Staff and residents confirmed the lack of policy enforcement, and the administrator acknowledged the safety failure.
The facility failed to protect residents from physical and sexual abuse, resulting in one resident sustaining injuries from an altercation with another resident and another resident being inappropriately touched by a fellow resident. Staff were aware of the behavioral issues but did not adequately monitor or intervene to prevent these incidents.
The facility failed to store and handle food in a sanitary manner in one of its kitchens. Observations included uncovered, unlabeled, and undated food items in the refrigerator and freezer, as well as spilled prune juice. The administrator confirmed these issues.
The facility failed to accommodate a resident's lighting needs, leaving them unable to reach the overbed light switch due to a short cord. Despite reporting the issue, it remained unresolved. The Maintenance Director and Administrator acknowledged the problem and the need for repair.
The facility failed to obtain copies of advance directives and inform two residents of their right to formulate advance directives. One resident had a care plan indicating an advance directive, but no documentation was found in their health record. Another resident had no documentation or discussion about advance directives despite being their own responsible party.
A resident with severe cognitive decline and chronic conditions was sent out of the facility for an appointment without notifying her/his representative, as required by the admission agreement. The Administrator acknowledged this lapse in notification.
A resident with a non-pressure chronic ulcer and type 2 diabetes, who was moderately cognitively impaired, was found to have a gouge in the wall adjacent to their bed. The Maintenance Director acknowledged the issue and stated it should have been fixed before the resident moved in. The Administrator also deemed the condition unacceptable.
The facility failed to provide a written summary of a baseline care plan within 48 hours of admission for two residents. Both residents, admitted with serious health conditions, did not receive their baseline care plans, and staff members were unaware of the requirement to provide and review these plans.
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with PTSD. Although the resident's admission MDS noted the PTSD diagnosis and indicated the need for interventions, the comprehensive care plan lacked focus, goals, or interventions for PTSD symptoms. The Social Services Director confirmed the oversight.
The facility failed to follow physician orders for a resident with lymphedema and erythema. The resident's ACE wraps were not applied on multiple dates in May, and the resident was observed wearing ragged wraps that had not been removed for a week. Staff confirmed the non-compliance with the physician's orders.
The facility failed to provide adequate care and hazard removal for two residents. One resident, with obesity and dementia, fell out of bed when only one staff member was present during care, despite a care plan requiring two. Another resident, with severe cognitive impairment, was found with electric burners in their room, which staff were unaware of until they were removed by the Administrator.
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. One resident with COPD had a dusty oxygen concentrator filter, and another resident with congestive heart failure received an incorrect oxygen flow rate. Staff acknowledged these issues, and the DNS confirmed the expectations for equipment maintenance and oxygen level checks.
The facility failed to accurately document wound care for a resident with lymphedema and erythema. Despite physician's orders to apply and remove ACE wraps daily, records showed inconsistencies, and the resident reported wearing the same wraps for a week without removal. An observation confirmed the wraps were ragged and nearly falling off, and staff acknowledged the documentation inaccuracies.
Failure to Provide Written Transfer Notices and Bed-Hold Policy at Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice of transfer and written information on the facility’s bed-hold policy at the time of hospital transfer for three residents. The facility’s 7/2018 Notification of Changes of Condition Policy directs staff to promptly notify the resident representative when there is a decision to transfer a resident to the hospital. For one resident admitted in 6/2024 with diagnoses including urinary tract infections and sepsis, the admission profile indicated the resident was responsible for themselves, and the clinical record showed a hospital transfer on 2/12/26 with no evidence that written notice of transfer or the facility’s bed-hold policy was provided. Another resident, admitted in 2/2025 with peripheral vascular disease and whose admission profile identified their daughter as the responsible party, was transferred to the hospital on two occasions, with no documentation that the representative was notified of either transfer. A third resident, admitted in 4/2025 with chronic heart failure and responsible for their own decisions, was transferred to the hospital on 2/12/26 without any documented evidence that written notice of transfer or the facility’s bed-hold policy was provided. During interviews, one LPN stated she did not document which documents were sent with residents transferring to the hospital and confirmed the facility did not have written transfer notices to provide to residents or representatives. Another LPN reported being unaware of the requirement to provide a bed-hold policy or transfer notice when residents were transferred. The DNS was unable to locate any documentation confirming that the bed-hold policy or written transfer notifications were provided to the three residents or their representatives, and stated she was unaware that written transfer notification was required, while the Administrator acknowledged that written transfer notification and the bed-hold policy were supposed to be provided at the time of transfer.
Failure to Honor Resident Choice of CNA Caregiver
Penalty
Summary
Surveyors identified a failure by the facility to honor a resident’s right to self-determination and choice of health care providers. The facility’s Resident Rights: Right to Self-Determination Policy, dated 7/2018, stated that residents have the right to choose health care and providers of health care services and that the facility would promote and facilitate resident self-determination and autonomy. Resident 1, admitted with Parkinson’s disease and anxiety, had a trauma care plan revised on 5/30/25 instructing staff to involve the resident in cares and daily decisions, and Minimum Data Set (MDS) assessments indicated no cognitive impairment. Despite this, Resident 1 repeatedly told several staff members and administration that they did not want Staff 3, a CNA, in their room or providing care. The resident reported that they had tried multiple times to have Staff 3 not work with them, but Staff 3 continued to be assigned and was their CNA on the day of observation. Record review of staff assignment sheets from 3/24/26 through 4/6/26 showed that Staff 3 was assigned to care for Resident 1 on multiple days within that period, and surveyor observations confirmed Staff 3 provided care and services to the resident during the day shift. Staff 3 acknowledged that the resident did not like them as their CNA and that nursing staff and upper management were aware, yet they continued to be assigned to the resident. Another CNA confirmed that Resident 1 did not want Staff 3 assisting them. Social services staff stated the resident had reported not wanting Staff 3 as their CNA several times and that this concern had been discussed among staff for a while, with the information passed to the Administrator and DNS. The staffing coordinator/human resources staff confirmed the resident’s complaints and stated that CNA assignment changes were made if a teammate requested a change, and that leadership was aware of the resident’s request. The DNS acknowledged awareness of the resident’s wishes, confirmed the repeated assignments of Staff 3 to the resident, and stated that although it was the resident’s right to choose who cared for them, there were staffing challenges and many considerations in CNA assignments.
Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of hospital transfers as required by its Notification of Changes of Condition Policy. The policy, dated 7/2018, directed staff to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital. Resident 4, admitted in 2/2025 with diagnoses including peripheral vascular disease, had an admission profile listing Witness 4 as the responsible party and emergency contact. Record review showed that the resident was transferred to the hospital on two occasions, including 12/18/25, with no documentation in the clinical record that the resident’s representative was notified of these transfers. During interviews, nursing staff confirmed that the practice was to notify the emergency contact or responsible party listed on the face sheet before or immediately after a resident left the facility and to document this in the clinical record. Specifically, two LPNs stated that family or the listed emergency contact were to be contacted when residents transferred to the hospital and that they documented who was contacted. However, on 4/7/26, the DNS and the Administrator confirmed that Witness 4 was not notified when the resident was transferred to the hospital on 12/18/25 and acknowledged that nursing staff were not contacting resident representatives as required, leading to the identified deficiency.
Failure to Prevent Sexual Abuse by Resident With Known History of Sexual Behaviors
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a cognitively impaired resident with a known history of sexually inappropriate behavior was allowed to be alone with another cognitively impaired resident. Facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident who lacked the cognitive ability to consent or did not want the contact. One resident had relapsing multiple sclerosis, mild cognitive impairment, and was assessed on a quarterly MDS as having severe cognitive impairment. This resident’s care plan documented past sexual assault trauma, a preference for female staff, and impaired cognition. Another resident, admitted with alcohol-induced persisting dementia and high-risk heterosexual behavior, was assessed as having moderate cognitive impairment. That resident’s care plan identified a history of sexual behaviors toward female residents and directed staff to ensure supervision when around female residents, to redirect sexual behaviors, and to place the resident on intermittent 1:1 supervision after incidents for the safety of others. Clinical record review for the resident with sexually inappropriate behaviors showed multiple prior incidents, including an attempt to touch a female resident, being found in female residents’ rooms, sexually touching female staff, and increased sexual behaviors, with no evidence that 1:1 supervision was implemented after these events as care planned. Multiple CNAs reported that this resident was not supposed to be alone with female residents and that staff were expected to redirect the resident from entering rooms or demonstrating sexual behaviors when not on 1:1 supervision. Despite this, the staffing coordinator/human resources staff member observed the resident in the dining room with a hand under the other resident’s shirt, fondling the resident’s breast, while the victim attempted to push the hands away, and no other staff were present in the area. The administrator and DNS confirmed that the resident had a known history of sexual behaviors toward others and acknowledged that this incident constituted abuse.
Failure to Assess Resident's Ability to Use Power Wheelchair
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination regarding the use of a power mobility device. A resident with a history of cerebral infarction and depression was admitted and had a goal, as documented in an occupational therapy evaluation, to operate a power wheelchair with standby assist to maximize socialization. Despite this, therapy records showed that while the resident received services aimed at improving skills related to power wheelchair use, no actual assessment involving the use of the power wheelchair was performed. Scheduled power wheelchair training sessions did not occur, and the decision to discontinue the use of the device was based on perceived deficiencies in tactile feedback and visual scanning, without direct assessment of the resident's abilities in the power wheelchair. Interviews and observations revealed that the resident expressed a desire to use the power wheelchair to increase independence and socialization, and staff noted improvements in the resident's functional use of hands and ability to perform self-care tasks. The resident was observed participating independently in activities requiring fine motor and visual scanning skills, and staff confirmed improvements in these areas. Despite these observations and the resident's normal cognitive function, the facility did not conduct a direct assessment of the resident's ability to safely use the power wheelchair, as confirmed by the Director of Nursing Services.
Failure to Complete Required PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure appropriate completion of PASARR (Preadmission Screening and Resident Review) screenings for two of three sampled residents with mental disorders or intellectual disabilities. One resident, admitted with diagnoses of schizophrenia and anxiety, had a PASARR I assessment indicating the need for a PASARR II due to the schizophrenia diagnosis, but no PASARR II was found in the electronic health record. Staff confirmed that the required PASARR II had not been completed. Another resident, admitted with bipolar disorder and PTSD, did not have a PASARR I screening available in the record at the time of the survey. Staff interviews confirmed that the PASARR I was not completed for this resident upon admission, as required by facility policy.
Failure to Honor and Provide Resident Activity Preferences
Penalty
Summary
The facility failed to ensure that activities were honored and provided according to the preferences and needs of a resident with dementia and PTSD, who had a severe cognitive impairment as indicated by a BIMS score of six. The resident's admission MDS documented that it was very important for them to be around animals, do favorite activities, go outside in good weather, and listen to preferred music. However, the care plan only noted a general enjoyment of music and did not include specific preferences such as pet visits, listening to chosen music, group activities, or going outside. Observations over several days showed the resident sitting alone in common areas with little to no staff interaction and not being included in group activities occurring nearby. Interviews with the resident, their representative, CNAs, and the Activities Director confirmed that the resident enjoyed country and older rock music, liked dogs, and would participate in activities if invited. Staff were either unaware of the resident's preferences or had not included the resident in one-on-one visits or group activities. The Activities Director acknowledged that key preferences were missing from the care plan and were not being offered. The Administrator confirmed that the care plan did not reflect the resident's activity preferences and that activities were not being offered as expected.
Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned transfer interventions for a resident with a right leg amputation who required two-person assistance with a mechanical lift for transfers from bed to a shower chair. Despite the care plan in place, the resident was transferred by a single CNA without the use of a mechanical lift, contrary to the documented requirements. This resulted in the resident experiencing a fall during the transfer process. Interviews revealed that the CNA acted based on the resident's statement that they no longer needed the mechanical lift and only required assistance from one staff member, as the resident was working with therapy on slide board transfers. However, the care plan at the time of the incident still required a two-person mechanical lift transfer, and staff were expected to review and follow the care plan. The Director of Nursing Services acknowledged that the care plan was not followed in this instance.
Failure to Review and Document Rationale for Duplicate Antibiotic Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis and later received a second antibiotic, cefuroxime, without documented review or rationale for the concurrent use of both antibiotics. The resident was initially admitted with acute kidney failure, dysuria, and urinary retention, and was placed on Bactrim for ongoing UTI prevention. After reporting symptoms suggestive of a UTI, the resident was evaluated in the emergency department, where no infection was found. Subsequently, the resident's primary care provider prescribed cefuroxime following a urine dipstick that showed trace leukocytes, resulting in the resident receiving both antibiotics simultaneously. Facility staff, including nursing and infection control personnel, recognized the duplicate antibiotic therapy and attempted to contact the resident's primary care provider for clarification regarding the necessity of both medications. Despite these attempts, there was no response from the provider, and no documentation was made to justify the dual antibiotic regimen. The facility's antibiotic stewardship policy required validation of antibiotic use for correct indication, dose, route, and duration, but this was not followed in this case, as there was no documented rationale for the continued use of both antibiotics.
Failure to Enforce Smoking Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement and enforce its smoking policy, resulting in a resident sustaining a second-degree burn. The facility's smoking policy, dated January 20, 2023, required that smoking and smoking paraphernalia be managed and distributed by staff, with residents returning all smoking materials to a centralized storage box after use. However, the facility did not enforce this policy, allowing residents to possess and use smoking materials independently. This lack of enforcement led to an incident where a resident, admitted in February 2024 with chronic kidney disease, sustained burns while refilling another resident's butane lighter. The incident occurred on October 4, 2024, when the resident set their hand on fire while attempting to refill the lighter. The resident suffered burns to the middle, ring, and little fingers of their left hand. Interviews with the resident and another resident confirmed that the facility did not enforce the return of smoking materials, and staff acknowledged the facility's inability to manage the smoking policy. The facility administrator admitted the failure to ensure resident safety concerning the possession and management of smoking paraphernalia.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical and sexual abuse, as evidenced by two incidents involving residents. In the first incident, Resident 12, who had dementia and a communication deficit, was found on the floor with multiple skin tears after an altercation with Resident 17, who had a history of physical aggression and dementia. Staff were aware of both residents' behavioral issues, including Resident 12's tendency to wander into other residents' rooms and Resident 17's aggressive response to personal space invasion. Despite this knowledge, the facility did not adequately monitor or intervene, resulting in Resident 12 being injured by Resident 17 during an altercation in Resident 17's room. Staff confirmed that Resident 12's fragile skin could easily tear from physical contact, which was evident in this incident. Both residents were unable to recall the altercation due to their cognitive impairments, but staff and a housekeeper witnessed the aftermath and confirmed the physical altercation and injuries sustained by Resident 12. The facility's failure to consistently check on Resident 12's whereabouts and intervene as necessary to protect residents' safety led to this incident of physical abuse. In the second incident, Resident 3, who was cognitively intact, reported that Resident 33, who also had dementia but was ambulatory, touched her/his breast inappropriately. Resident 3 stated that Resident 33 entered her/his room, made an inappropriate comment, and then grabbed her/his breast before leaving. This incident was witnessed by Resident 3's roommate, who confirmed the inappropriate touching. Resident 3 reported the incident to a nurse later that evening, and the nurse confirmed that Resident 3 did not exhibit any changes in mood or behavior following the incident. Resident 33 denied the inappropriate touching and did not recall the incident. The facility's failure to prevent this incident of sexual abuse highlights a lack of adequate supervision and intervention to protect residents from abuse by other residents.
Unsanitary Food Storage and Handling
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in one of its two kitchens, specifically the dining room kitchenette. During an initial tour, several issues were observed: a piece of cake with whipping cream was not covered, labeled, or dated; a small plastic container with an unknown substance was not labeled or dated; a covered plate with a pork chop, baked potato, and corn was not labeled or dated; a tray with multiple covered juice drinks was not labeled or dated; and an opened container of prune juice had spilled onto lower shelves and the floor. In the freezer, seven small plastic containers with unknown substances were not labeled or dated; two individual strawberry yogurt containers had a use-by date that had passed; two opened one-pint ice cream containers with resident names were not dated; an opened gallon of chocolate ice cream did not have a secure lid and was not dated; and three small plastic containers of fish snack crackers on top of the refrigerator were not labeled or dated. The administrator confirmed these items were not appropriately stored.
Failure to Accommodate Resident Lighting Needs
Penalty
Summary
The facility failed to ensure resident needs and preferences related to lighting were accommodated for one resident reviewed for accommodation of needs. Resident 13, admitted with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had moderately impaired cognition. The resident reported on multiple occasions that the overbed light switch had a short cord, making it inaccessible. Despite reporting this issue to staff, it remained unresolved. The Maintenance Director acknowledged the problem and stated that maintenance issues should be reported through the facility's work order system or via word of mouth. The Administrator confirmed that residents should be able to control their lighting and that the pull cord needed repair.
Failure to Obtain and Discuss Advance Directives
Penalty
Summary
The facility failed to obtain copies of advance directives and inform residents of their right to formulate advance directives for two residents. Resident 8, admitted in August 2017 with diagnoses including Type 2 Diabetes and morbid obesity, had a care plan indicating the presence of a Living Will or other Advance Directive. However, there was no evidence in Resident 8's health record that the facility obtained a copy of the advance directive or discussed it with the resident since the care plan intervention was initiated in June 2023. The facility administrator acknowledged this oversight during an interview on May 30, 2024. Similarly, Resident 13, admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and Type 2 Diabetes, had no documentation in their health record indicating the presence of an advance directive or that staff discussed the creation of one with the resident. Despite the resident being their own responsible party and having moderately impaired cognition, the facility did not address the advance directive discussion. The administrator confirmed this lapse during the same interview on May 30, 2024.
Failure to Notify Resident's Representative of Out-of-Facility Appointment
Penalty
Summary
The facility failed to notify a resident's representative of an appointment out of the facility. Resident 289, who was admitted in December 2016 with diagnoses including chronic congestive heart failure and type 2 diabetes, had severe cognitive decline as noted in an 8/29/22 CAA. The resident's admission agreement indicated that her/his representative/legal guardian was her/his daughter. On 11/10/2022, Resident 289 was sent out of the facility for an appointment, but there was no evidence in the health record to indicate that the representative was notified. The Administrator acknowledged this lapse in notification on 6/3/24 at 2:16 PM.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident admitted in March 2024 with diagnoses including a non-pressure chronic ulcer and type 2 diabetes. The resident's cognition was moderately impaired as per the Admission MDS reviewed on April 4, 2024. On May 29, 2024, a gouge approximately 16 inches in length and 36 inches above the floor was observed in the wall adjacent to the head of the resident's bed. The Maintenance Director acknowledged the gouge on June 3, 2024, and stated it should have been fixed prior to the resident moving into the room. The Administrator also stated that the gouge was unacceptable and that residents' rooms should be painted and homelike before they move in.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a written summary of a baseline care plan was provided to residents within 48 hours of admission for two of the four sampled residents. Resident 7, admitted with diagnoses including kidney failure and anxiety, did not have a baseline care plan reviewed or provided. Resident 7 confirmed not receiving a baseline care plan. Staff members, including an LPN and an RNCM, were unaware that baseline care plans needed to be provided and reviewed with residents. Similarly, Resident 241, admitted with diagnoses including heart failure and high cholesterol, also did not have a baseline care plan reviewed or provided. Staff members again confirmed their lack of awareness regarding the requirement to provide and review baseline care plans with residents.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted in January 2024, and the Mood State CAA from the resident's February 2024 Admission MDS noted the PTSD diagnosis and indicated that the care plan should address PTSD symptoms with interventions to assist with mood. However, a review of the resident's comprehensive care plan, last revised in April 2024, revealed no focus, goals, or interventions for the resident's PTSD symptoms. The Social Services Director confirmed that although a PTSD evaluation was completed, the comprehensive care plan related to PTSD symptoms was not completed.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders regarding wound care for a resident diagnosed with lymphedema and erythema. The physician's order from April instructed staff to apply ACE wraps to the resident's lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May showed that the ACE wraps were not applied on multiple dates. Additionally, the resident was observed wearing ragged ACE wraps that had not been removed for a week, contrary to the physician's orders. Staff confirmed that the resident was not wearing the ACE wraps as ordered during an observation on May 31.
Inadequate Care and Hazard Removal for Two Residents
Penalty
Summary
The facility failed to provide adequate care and hazard removal for two residents. Resident 239, admitted with diagnoses including obesity and dementia, had a care plan requiring two staff members to be present during care. However, on one occasion, only one staff member was present, resulting in the resident rolling out of bed. This was confirmed by both the CNA and the Administrator. Resident 240, admitted with severe cognitive impairment, was found with two unplugged electric burners on the floor of their room. The resident intended to use them, but staff were unaware of their presence until they were discovered and removed by the Administrator.
Failure to Maintain Oxygen Equipment and Administer Oxygen as Ordered
Penalty
Summary
The facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for two residents. Resident 4, who was admitted with multiple sclerosis and chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator with a thick layer of dust on the external filter. Staff acknowledged that the filter was not clean, despite the expectation that external filters should be cleaned once a month. This observation was confirmed by both an LPN and the Director of Nursing Services (DNS). Resident 21, admitted with congestive heart failure and chronic respiratory failure, was observed using an oxygen concentrator with a flow rate of 2.5 liters, contrary to the physician's order of 1.5 liters. Additionally, the external filter on this concentrator also had a thick layer of dust. Staff acknowledged the discrepancy in the oxygen flow rate and the unclean filter. The DNS confirmed that oxygen levels should be checked at the beginning of each shift and filters cleaned monthly.
Failure to Accurately Document Wound Care
Penalty
Summary
The facility failed to accurately document wound care being provided in accordance with physician's orders for a resident with lymphedema and erythema. The resident was admitted in January 2018 and had normal cognitive function as of January 2024. A physician's order from April 2024 instructed staff to apply ACE wraps to both lower extremities in the morning and remove them at night. However, the Treatment Administration Record (TAR) for May 2024 showed that the ACE wraps were documented as being off on multiple dates, despite the resident stating that the same ACE wraps had been worn for a week without being removed at night. An observation on May 28, 2024, confirmed the resident was wearing ragged ACE wraps that were nearly falling off. Staff later confirmed that the records regarding the ACE wraps were not accurately documented.
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A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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