Avamere Health Services Of Rogue Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Oregon.
- Location
- 625 Stevens Street, Medford, Oregon 97504
- CMS Provider Number
- 385024
- Inspections on file
- 23
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Avamere Health Services Of Rogue Valley during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a care plan requiring denture cleaning did not receive necessary oral care assistance from staff. Family members reported having to clean and insert the resident's dentures themselves, and staff interviews revealed inconsistent awareness and communication regarding the resident's denture care needs. Observations confirmed the resident wore dentures overnight and had mouth odor, indicating a lack of proper oral hygiene support.
The facility failed to address grievances raised by the resident council, including issues with staff respect, response times, follow-up on concerns, perceived retaliation, call light delays, noise levels, lack of snacks, poor food quality, lost items, insufficient activities, and untimely showers. The Activity Director did not forward the completed grievance form, and the Administrator did not receive it, resulting in unmet needs for the residents.
The facility failed to maintain a homelike environment, with observations of missing floorboards, damaged walls and doors, non-functional lights, unsafe furniture, moldy ceiling tiles, and tattered carpets held together with tape. These issues were acknowledged by the Administrator and Maintenance Director.
The facility failed to maintain water temperatures below 120°F in three resident bathrooms and did not follow or reassess fall prevention measures for a resident who experienced 30 falls. The resident's room was located at the end of the unit with minimal staff activity, and the facility did not implement new interventions despite the resident's high fall risk.
The facility failed to handle and prepare food in a sanitary manner, with observations of dirty coffee pots, improper temperature control of potato salad, and a dietary aide not following proper hand hygiene and glove use, as well as not wearing appropriate beard restraint.
The facility failed to ensure residents received medications as prescribed, were monitored for medication side effects, and provided wound care as ordered. One resident did not receive daily monitoring for anticoagulant and antidepressant medications, another did not receive prescribed Folic Acid, and two residents did not receive wound care as ordered, leading to worsened conditions.
The facility failed to provide adequate staffing, resulting in long call light wait times and unmet care needs for residents. Multiple residents reported waiting from 10 minutes to over an hour for assistance, leading to incontinence episodes and falls. Staff confirmed the facility was often short-staffed, causing delays in care and supervision.
The facility failed to post accurate and complete staffing information from 11/23/23 through 12/15/23. A review of the Direct Care Staff Daily Reports (DCSDR) revealed missing staff hours on eight days, census documented only one day, and the number of staff not documented on two days. The Administrator and DNS were unaware of these issues, and the DNS noted that the Staffing Coordinator was new during this period.
A resident with mild dementia was prescribed Seroquel without proper assessment or rationale, leading to its discontinuation after one dose. The resident experienced falls and confusion, but staff did not document behaviors warranting psychotropic medication use. The facility failed to consult the resident's neurologist for medication management, and non-pharmacological interventions were not adequately explored.
A resident with pernicious anemia reported feeling dismissed and hurt by a nurse's response when inquiring about medication timing. The nurse's dismissive comment and the lack of reporting by another staff member led to the deficiency.
The facility failed to assess a resident for a significant change in condition after the resident, admitted with infection and a pressure ulcer, started hospice services. An LPN confirmed that a required Significant Change MDS was not completed.
The facility failed to update a resident's care plan to reflect the use of a walkie talkie and call bell system for requesting assistance, despite multiple staff confirmations and an alert note indicating the call light was ineffective due to the room's location. This oversight placed the resident at risk for unmet needs.
A resident with pernicious anemia did not receive their required daily vitamin B12 medication due to a delay in pharmacy documentation and delivery. The resident, who was cognitively intact and had severe spinal cord degeneration, reported the missed dose, which was confirmed by staff.
The facility failed to maintain a medication error rate below 5%, resulting in a 7% error rate. One resident received levothyroxine with food instead of on an empty stomach, and another resident did not receive their Cranberry D-Mannose supplement due to a supply oversight.
The facility failed to follow menus for two residents, leading to unmet food preferences. One resident with diabetes received scrambled eggs instead of poached eggs and no drinks, while another resident with adult failure to thrive received incorrect breakfast and lunch items, including missing a hash brown patty and chocolate ice cream.
A resident with diabetic neuropathy and at nutritional risk did not receive necessary adaptive equipment during meals. The resident's care plan required a two-handle cup and a lip plate, but these were not consistently provided, leading to unmet needs. Staff acknowledged the oversight.
A facility failed to ensure accurate medical records for a resident with high blood pressure. Despite physician orders to document blood pressure before administering lisinopril, staff marked 'NA' on multiple dates in the MARs, admitting that readings were taken but not recorded. This oversight placed the resident at risk for inappropriate treatment.
The facility failed to monitor antibiotic use for a resident with a history of MDRO and chronic urinary tract infections. The resident was prescribed cephalexin without a culture and sensitivity test, and an antibiotic time-out was not completed as required.
A resident with kidney failure and difficulty walking reported multiple instances of staff yelling and refusing care, including derogatory comments and denial of medications, leading to the resident leaving the facility AMA. The involved staff were suspended, and an investigation confirmed the resident's claims.
The facility failed to resolve grievances for two residents. One resident's concerns about food being thrown away were not addressed, and another resident's request to avoid care from a specific LPN was ignored, leading to continued care by the LPN despite safety concerns.
The facility failed to protect a resident from abuse when another resident, with a history of physical aggression, yanked their hair after a verbal altercation. Despite staff intervention, the incident highlighted a lapse in ensuring resident safety.
The facility failed to maintain healthy nutritional parameters for three residents, leading to significant weight loss and inadequate nutritional intake. One resident experienced an 8% weight loss without a follow-up Nutritional Assessment, another had severe malnutrition with inconsistent weight documentation, and a third had inadequate meal intake with minimal documentation of nutritional interventions.
The facility failed to maintain ongoing communication with the dialysis center for a resident with chronic kidney disease, resulting in a nearly month-long gap in documentation. This lapse was confirmed by an LPN and the DNS, who could not provide the missing forms.
Failure to Provide Denture and Oral Care Assistance
Penalty
Summary
A resident with diagnoses including COPD and dementia, and a BIMS score indicating severe cognitive impairment, was admitted to the facility and required set-up assistance for oral hygiene. The resident's care plan specified that oral care should include cleaning full upper and partial lower dentures. Despite these documented needs, family members reported that during a 72-hour stay, they had to clean and insert the resident's dentures themselves because staff did not provide assistance. Observations confirmed the resident had mouth odor and admitted to wearing dentures overnight, contrary to care plan instructions. Staff interviews revealed inconsistent awareness and implementation of the resident's oral care needs. One CNA stated there was a note in the resident's room to ensure denture care, but acknowledged finding the dentures in the resident's mouth in the mornings and did not inform nursing staff of the issue. Another CNA was unaware the resident wore dentures, despite assisting with oral care in the evenings. The LPN-Resident Care Manager confirmed that dentures were to be cleaned in the morning and evening and removed at night, and expected staff to communicate care concerns to ensure proper oral hygiene. These findings indicate a failure to provide necessary assistance with oral care as required by the resident's care plan.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances raised by the resident council, as evidenced by the Bi-Monthly Resident Counsel Questions form completed on 4/10/24. The form highlighted several concerns, including residents not feeling respected by staff, staff not listening to or responding to their needs timely, and staff not following up on concerns. Additional issues included perceived staff retaliation, delayed call light responses, unacceptable noise levels, lack of bedtime snacks, poor food quality, lost items not being replaced, insufficient activities, and untimely showers. During a resident council meeting on 4/17/24, residents reiterated that these concerns had not been addressed by the facility staff. On 4/19/24, the Activity Director (Staff 21) confirmed that the Bi-Monthly Resident Counsel Questions form process was initiated on 4/10/24 but admitted she did not forward the completed form to anyone. The Administrator (Staff 1) also confirmed that he did not receive a copy of the form and acknowledged that grievances should be addressed within five days. The failure to forward and address the grievances resulted in unmet needs for the residents, as the concerns raised on 4/10/24 were not acted upon by the facility staff.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as evidenced by multiple observations of unkempt and unsafe conditions. Specific issues included a missing floorboard in one room, a bathroom door with a large chunk missing, and wall damage with missing paint in several rooms. Additionally, lights were not working in the 200 hall, and a small round table in the smoking area had sharp and jagged edges. The double doors at the end of the 100 hall were covered with cobwebs, residual tape, and splatter marks. A ceiling tile outside one room was damaged and appeared to have mold. The transition strip in the large dining room was torn and peeling, and the carpet in various areas of the facility was tattered and held together with black tape. Further observations revealed that the carpet along the entryway where mechanical lifts were stored was torn and tattered, and there were gaps along the transition strip. The nurse's station on Hall 100 had approximately three to four feet of tattered carpet, and Hall 200 had two areas near the fire doors and the nurse's station with black tape holding the carpet together. The main entryway had a large section of loose carpet with waves and wrinkles. These issues were acknowledged by the Administrator and the Maintenance Director, indicating a need for addressing these concerns to ensure a safe and homelike environment for the residents.
Failure to Maintain Safe Water Temperatures and Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to maintain water temperatures below 120°F in three resident bathrooms, with temperatures recorded at 123°F, 125°F, and 121°F. This issue was identified during an inspection with the Maintenance Lead, and the Administrator acknowledged the problem, indicating that the water heater was new and adjustments would be made. Residents in these rooms required varying levels of assistance for toileting, placing them at risk of injury due to the elevated water temperatures. Additionally, the facility failed to follow care plan interventions, assess for care plan effectiveness, and implement new fall interventions for a resident admitted in August 2023 with diagnoses including infection and pressure ulcer of the lower spine. The resident, who had no cognitive impairments initially but later developed moderate cognitive impairments, experienced 30 falls from October 2023 to April 2024. Despite multiple falls, the facility did not consistently implement new fall prevention measures or reassess the effectiveness of existing interventions. Observations revealed that the resident's room was located at the end of the unit with minimal staff activity, and the resident did not use the call light for assistance. Staff interviews confirmed that the resident was a high fall risk and would benefit from being closer to the nurses' station, but no appropriate beds were available. The facility's failure to adequately supervise the resident and reassess fall prevention measures placed the resident at continued risk of falls and potential injury.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to handle and prepare food in a sanitary manner, as observed during a survey. On the morning of the survey, dirty coffee pots were noted on the beverage carts for two wings, which were acknowledged by the Dietary Services Manager as needing deep cleaning. During lunch preparation, a dietary aide was observed performing a temperature check on all food, finding the potato salad at 51 degrees instead of the required 41 degrees, but no further action was taken to address this. The dietary aide also failed to maintain proper hand hygiene and glove use, touching various surfaces and his face without changing gloves or washing hands, and did not wear appropriate beard restraint, leading to potential contamination of food items. The dietary aide was seen handling food with both utensils and gloved hands, leaving the steam table multiple times to retrieve items from the refrigerator without changing gloves or performing hand hygiene. He also touched his nose and watch, and discarded a glove on top of a tote containing uncovered potato salad. The aide acknowledged the break in infection control practices, including the need to change gloves, perform hand hygiene, wear a beard restraint, and recheck the temperature of the potato salad before serving it to residents.
Failure to Administer Medications and Provide Wound Care as Ordered
Penalty
Summary
The facility failed to ensure residents received medications as prescribed, were monitored for medication side effects, and provided wound care as ordered. Resident 8, who was admitted with diagnoses including depression and irregular heartbeat, had no documentation in clinical records indicating daily monitoring of side effects for anticoagulant and antidepressant medications. Staff acknowledged that such monitoring should be in the physician's orders and conducted daily, but it was not done for Resident 8. Resident 52, admitted with a diagnosis of pernicious anemia, did not receive prescribed Folic Acid from 4/13/24 through 4/16/24. Progress notes indicated the medication was on order and waiting for pharmacy delivery, but it was later revealed that Folic Acid was available in the central supply closet and should have been administered. This oversight resulted in a failure to provide necessary medication for the resident's condition. Resident 58, admitted with an infection in a right foot wound, did not receive wound care as ordered on 8/24/23 and 8/25/23. The wound care was passed to the next shift but not completed, leading to maggots being found in the wound and increased redness. Similarly, Resident 59, with a pressure injury to the sacrum, had missed wound care documentation on 5/19/23 and 5/20/23. Staff 15 was accused of falsifying records by signing that wound care was completed when it was not. The facility acknowledged the missed documentation and the failure to complete wound care as ordered for both residents.
Inadequate Staffing and Long Call Light Wait Times
Penalty
Summary
The facility failed to have adequate staff available to timely meet the needs of residents, as evidenced by multiple instances of long call light wait times and unmet care needs. Residents reported waiting from 10 minutes to over an hour for assistance, particularly during the evening and night shifts. Several residents experienced incontinence episodes and falls due to the lack of timely response from staff. Interviews with residents and staff confirmed these delays, with staff acknowledging the facility was often short-staffed and overwhelmed, leading to inadequate care and supervision. Resident 32, who was admitted with diagnoses including stroke and dementia, was left in a soiled brief for extended periods due to insufficient CNA staffing. The facility failed to meet state minimum staffing requirements on several occasions, and a public complaint highlighted that Resident 32's family member observed the resident sitting in a wet brief because staff were not available to assist. Staff confirmed the resident's complaints about long wait times and inadequate care. Resident 60, admitted with diagnoses including anxiety and a pressure ulcer, also experienced significant delays in care. The resident called the police for help after being left in urine and unable to reach staff. Documentation revealed gaps in care, and a public complaint indicated the resident had to call a family member and 911 for assistance. Staff confirmed the facility was short-staffed, leading to long call light wait times and residents' needs not being met. Additionally, Resident 160, who required assistance with toileting, reported waiting 45 minutes for help and observed staff ignoring call lights. Staff confirmed that a former CNA had a history of not answering call lights and was eventually terminated for these issues.
Failure to Post Accurate and Complete Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, for the period from 11/23/23 through 12/15/23. A review of the Direct Care Staff Daily Reports (DCSDR) revealed that no staff hours were documented on eight days, the census was documented only one day, and the number of staff was not documented on two days out of the 23 days reviewed. On 4/19/24 at 7:39 AM, the Administrator and the Director of Nursing Services (DNS) stated they were unaware of the issues with the DCSDR reports. The DNS mentioned that the Staffing Coordinator was newer to the facility during the reviewed time period.
Failure to Assess and Document Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed before the prescription and use of psychotropic medications. Specifically, Resident 29, who was admitted with a diagnosis of mild dementia without behaviors, was prescribed Seroquel without an assessment or rationale documented in the clinical record. The resident's progress notes indicated that the resident was alert, oriented, and adjusting well to the facility environment, with no unwanted behaviors noted. Despite this, Seroquel was added to the resident's medication regimen, and the resident's daughter was not informed of the rationale for this decision, leading to the medication being discontinued after one dose. Subsequent progress notes revealed that Resident 29 experienced several falls and exhibited some confusion but was easily redirected by staff. The resident's clinical record did not contain any assessments or rationales for the initiation of Seroquel or Nuplazid, another psychotropic medication started later. Interviews with staff and the resident's family confirmed that there was no documentation of behaviors that would warrant the use of these medications, and the resident's neurologist was not consulted for medication management despite the resident's Parkinson's disease diagnosis. The facility's failure to document assessments and rationales for the use of psychotropic medications placed Resident 29 at risk for over-sedation and other potential adverse effects. Staff acknowledged the lack of documentation and were unable to provide additional information to justify the use of these medications. The resident's condition, including falls and confusion, was not clearly linked to the need for psychotropic medication, and non-pharmacological interventions were not adequately explored or documented prior to the initiation of these medications.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the experience of one resident who was admitted with a diagnosis of pernicious anemia. The resident, who was cognitively intact, reported feeling ill for up to four hours after taking a necessary medication and preferred to take it in the morning. On one occasion, when the resident asked a nurse about the timing of the medication, the nurse responded dismissively, stating she would administer it when she wanted to. This response hurt the resident's feelings and made them feel like an inconvenience. Staff interviews revealed that the nurse involved denied any verbal interactions about administering the medication on her time. Another staff member confirmed that the resident had reported feeling spoken to in an undignified manner but did not report it to management, believing it was not verbal abuse. The Director of Nursing Services stated that any such reports should be investigated and staff educated as needed. The nurse involved eventually acknowledged making the dismissive comment to the resident.
Failure to Assess Significant Change in Condition
Penalty
Summary
The facility failed to assess a resident for a significant change in condition. Resident 6, who was admitted in August 2023 with diagnoses including infection and a pressure ulcer of the lower spine, was referred to hospice services on December 14, 2023, and started hospice services on December 20, 2023. However, a review of the resident's Minimum Data Set (MDS) records indicated that a Significant Change MDS was not completed after the resident began hospice services. This was confirmed by Staff 19, an LPN Unit Manager, during a review of the MDS records on April 18, 2024.
Failure to Update Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of a resident. Resident 7, who was admitted in October 2017 with diagnoses including diabetes and major depressive disorder, had a care plan initiated on September 20, 2023, which instructed the resident to use a call light, walkie talkie, or phone to call the nurses' station if assistance was needed. However, a quarterly MDS assessment in February 2024 revealed that the resident was cognitively intact, and a Kardex dated April 15, 2024, indicated that staff should encourage the resident to use the call light for needs. Despite this, an alert note from March 18, 2024, indicated that the resident was reminded to use the call bell system or walkie talkie because the call light could not be seen or heard from the hall where the resident's room was located. Multiple staff members confirmed that the resident used a walkie talkie or call bell system for assistance, as the call light was ineffective due to the room's location. On April 18, 2024, the LPN Unit Manager reviewed Resident 7's care plan and acknowledged that it did not accurately reflect the resident's current method of calling for assistance. The Director of Nursing Services (DNS) also confirmed that the resident was instructed not to use the call light and to use the other provided devices for staff assistance. The DNS stated that care plans should be updated with any changes, indicating a failure to revise the care plan to reflect the resident's actual needs and methods for requesting assistance. This oversight placed the resident at risk for unmet needs due to the outdated care plan instructions.
Failure to Administer Required Medication
Penalty
Summary
The facility failed to ensure a resident's medication was available for administration, specifically for a resident diagnosed with pernicious anemia. The resident, who was cognitively intact and had severe spinal cord degeneration due to a vitamin B12 deficiency, reported that the facility did not have their required daily vitamin B12 medication available. The medication was not administered on one occasion, and staff noted that the pharmacy did not send the medication because it was not common to administer it daily. The initial order clarification was not documented by the pharmacy, leading to a delay and a missed dose of the medication.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7% error rate with two errors in 27 opportunities. One deficiency involved Resident 303, who was admitted with a diagnosis of a low-functioning thyroid. The resident's levothyroxine, which should be taken 15 to 60 minutes before breakfast, was administered with food. The resident, who was cognitively intact, confirmed that at home, they took the medication on an empty stomach. The LPN Unit Manager acknowledged that while administering levothyroxine with food might be acceptable for long-term residents, it might not be therapeutic for short-term residents like Resident 303. No scientific data was provided to support the practice of administering levothyroxine with food. Another deficiency involved Resident 30, who was admitted with a diagnosis of diabetes. The resident did not receive their Cranberry D-Mannose supplement because it was not available in the supply closet. The LPN responsible for administering the medication stated that they did not see the supplement on the higher shelf in the supply closet. Upon review, the supplement was found in the supply closet, indicating a failure in proper medication administration and inventory management.
Failure to Follow Menus for Two Residents
Penalty
Summary
The facility failed to ensure menus were followed for two residents, leading to unmet food preferences. Resident 8, who was admitted in 2018 with a diagnosis of diabetes, received scrambled eggs instead of poached eggs and did not receive any drinks as per the breakfast menu ticket on 4/17/24. The resident expressed dissatisfaction with the meal provided. Staff 1 (Administrator) and Staff 2 (DNS) confirmed that the kitchen was expected to provide the food items listed on the menu ticket for Resident 8. Resident 40, admitted in 2023 with a diagnosis of adult failure to thrive, also experienced issues with meal accuracy. On 4/17/24, Resident 40 received tater tots instead of the requested hash brown patty and did not receive bacon, which was not on the breakfast meal ticket. Additionally, during lunch, Resident 40 received a hamburger with a bun instead of an English muffin and did not receive the requested chocolate ice cream. Staff 1 and Staff 2 acknowledged that the kitchen should have provided the items listed on the meal ticket and noted that hash brown patties could have been made using tater tots if they were unavailable.
Failure to Provide Assistive Devices for Resident
Penalty
Summary
The facility failed to provide assistive devices for a resident with diabetic neuropathy, who was at nutritional risk and required adaptive equipment such as a two-handle cup and a lip plate. On multiple occasions, the resident did not receive the necessary adaptive equipment with their meals. Specifically, during breakfast, the resident did not receive a drink because the cup provided did not have adaptive handles, and during lunch, the resident was given a cup without adaptive handles. Staff acknowledged that the kitchen neglected to provide the required adaptive equipment as indicated in the resident's care plan and menu tickets.
Failure to Document Blood Pressure Readings
Penalty
Summary
The facility failed to ensure accurate medical records for a resident admitted in December 2023 with a diagnosis of high blood pressure. The physician's order required the resident to receive lisinopril daily, with specific instructions to hold the medication if systolic blood pressure was below 110 or diastolic blood pressure was below 60. However, the resident's Medication Administration Records (MARs) for March and April 2024 showed blood pressure readings marked as 'NA' on multiple dates. Upon review, staff admitted that blood pressure readings were taken but not documented as required. This failure to document the readings accurately placed the resident at risk for inappropriate treatment.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor antibiotic use for a resident with a history of multi-drug-resistant organisms (MDRO) and chronic urinary tract infections. The resident was admitted in July 2013 and had an order for cephalexin, an antibiotic, from February 17, 2024, to February 25, 2024, for a urinary tract infection. A urine analysis on February 16, 2024, indicated a small number of bacteria, but no culture and sensitivity test was completed to determine the appropriate antibiotic. The Director of Nursing Services (DNS) acknowledged that an antibiotic time-out, which should have occurred 48 hours after starting the antibiotic, was not completed.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by multiple instances of staff yelling at the resident and refusing to assist with care. The resident, who was admitted in 2023 with diagnoses including kidney failure and difficulty walking, was cognitively intact according to an Admission MDS. On one occasion, the resident asked for a shower and was told by a CNA to wait, followed by derogatory comments about the resident's weight and questioning why the resident was in the facility. The resident also reported being called a derogatory name and being dismissed by a nurse when the issue was raised. Additionally, the resident left the facility against medical advice (AMA) after being denied medications upon return from a dialysis appointment. The resident expressed concerns about dying without the medications, to which an LPN responded dismissively. The incident led to the suspension of the involved staff members, although some staff did not recall the events as described by the resident. The facility's management was notified, and an investigation was conducted, confirming the resident's departure AMA due to the staff's behavior.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were resolved or resolutions sustained for two residents. Resident 7, who was admitted with diagnoses including type 2 diabetes and major depressive disorder, expressed concerns about nursing staff throwing away her/his food without permission. Despite submitting grievances often via emails to the Administrator, no grievance was initiated or completed regarding this specific concern. This indicates a failure in the facility's grievance handling process as outlined in their policy dated 5/2000, which mandates prompt action on grievances received from residents and their families. Resident 29, admitted with a diagnosis of dementia, had a grievance submitted by a family member requesting that a specific night shift LPN not work with the resident due to safety concerns. Despite this request and a plan to ensure the resident felt safe, the LPN continued to provide care and administer medications to Resident 29, as documented in the clinical records. This failure to adhere to the grievance resolution plan placed the resident at risk and demonstrated non-compliance with the facility's grievance policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving Resident 19 and Resident 1. Resident 19, who was admitted in August 2020 with post laminectomy syndrome and was cognitively intact as per an 8/22/23 MDS, was subjected to physical aggression by Resident 1 on 9/9/23. Resident 1, who also was cognitively intact according to a 9/13/23 BIMS evaluation, yanked Resident 19's hair after Resident 19 ignored Resident 1's demand to vacate a spot in the hallway. Staff intervened and separated the residents, and Resident 19 was placed on alert charting. Resident 19 reported no pain or injuries from the incident. Despite the intervention, the facility's records revealed that Resident 1 had a resolved care plan for physical aggression toward another resident, indicating a history of such behavior. Interviews conducted on 4/18/24 and 4/19/24 confirmed the incident, with Resident 1 admitting to having a temper and acknowledging the possibility of such behavior. Observations from 4/15/24 to 4/18/24 showed that Resident 19 and Resident 1 did not interact during this period. The facility's failure to prevent this incident placed residents at risk for abuse.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to maintain healthy nutritional parameters for three residents, leading to significant weight loss and inadequate nutritional intake. Resident 32, who had a history of stroke and dementia, experienced an 8% weight loss from 148 pounds to 135 pounds within a month. Despite this significant weight loss, there was no documentation of a Nutritional Assessment or discussion by the Nutrition At Risk committee. The resident's nutritional supplement was discontinued due to gastrointestinal upset, but no alternative interventions were documented or implemented to address the weight loss. Resident 60, diagnosed with severe protein-calorie malnutrition, had a documented weight loss greater than 7.5% over three months. The resident's weight fluctuated significantly, and there were multiple instances where daily weights were not documented as required. Despite physician orders to provide a nutritional supplement and obtain daily weights, there was no consistent documentation or follow-up on the resident's nutritional status. Staff acknowledged potential issues with weighing procedures and the need for staff education. Resident 358, admitted with adult failure to thrive, had inadequate meal intake and significant weight loss. The resident's meal consumption was consistently low, with many instances of consuming only 0-25% of meals. Despite orders for nutritional supplements and meal replacements, there was minimal documentation of these interventions being offered or consumed. The resident's weights were not consistently recorded, and staff confirmed that meal replacements were not regularly offered despite the resident's poor intake. The facility's policy on weight monitoring and meal replacement was not followed, leading to further nutritional decline for the resident.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident with chronic kidney disease who was dependent on dialysis. The resident's care plan indicated scheduled dialysis days, but there were no communication forms between the facility and the dialysis provider for a period of nearly a month. This lapse was confirmed by the LPN Unit Manager, who acknowledged the importance of the communication form, and the Director of Nursing Services, who was unable to provide the missing documentation.
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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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