Avamere Rehabilitation Of Coos Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Coos Bay, Oregon.
- Location
- 2625 Koos Bay Blvd, Coos Bay, Oregon 97420
- CMS Provider Number
- 385239
- Inspections on file
- 22
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Coos Bay during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when the facility failed to maintain an emergency supply of glucagon for hypoglycemia and did not administer anti-seizure and muscle relaxant medications at the prescribed times. One resident with diabetes had multiple severe hypoglycemic episodes without access to glucagon, leading to repeated hospitalizations, while another resident received several medications hours late and in close succession, with no provider notification or alert charting completed.
Multiple residents with cognitive and physical impairments experienced prolonged call light response times, often waiting from 25 minutes to over an hour for assistance with toileting, transfers, and other needs. Staff and nursing leadership acknowledged that response times regularly exceeded the expected five to fifteen minutes, especially during busy periods, resulting in unmet needs and resident discomfort.
Surveyors found expired medications, including Metamucil, an acid reducer, and insulin vials, in the medication storage room, a medication cart, and a treatment cart. Staff and the DNS confirmed that expired medications should have been destroyed and replaced, and that insulin vials were not discarded within the required 28-day period after opening.
Surveyors found that the kitchen ice machine's drainpipe was installed without an air gap, as observed with the Dietary Manager. The issue had been previously identified by maintenance staff but was not corrected, and the Administrator was unaware of the deficiency prior to the survey.
The facility did not follow physician orders for four residents, resulting in failures such as lack of monitoring for fluid overload, missed and unavailable glucagon for hypoglycemia, unimplemented continuous glucose monitoring, incorrect insulin dosing, delayed antibiotic administration, and missed tube feedings. Staff acknowledged these errors and confirmed that orders were not consistently double-checked.
A resident with incontinence and diabetes did not consistently receive the correct size incontinence briefs as care planned, due to regular supply back orders. Staff confirmed that the resident often had to use smaller, uncomfortable briefs for several days every two weeks, and the issue was known to both supply and social services staff.
A resident with diabetes was hospitalized after experiencing low oxygen saturation, rapid pulse, and diarrhea, but the facility did not notify the resident's listed emergency contact or family member. The resident, who was cognitively intact, expected her family to be informed, and the family member confirmed she was not notified, only learning of the hospitalization after the resident returned and called her. The DNS stated staff did not notify family because the resident was her own responsible party.
A resident with heart failure and moderate cognitive impairment, who was prescribed an anticoagulant, developed unexplained bruising. Staff identified and reported the bruise, but the care plan was not updated to include the physician's order for anticoagulant therapy, despite the resident's increased risk for bruising and staff awareness of the medication.
A resident with a history of leg fracture and high fall risk was left unsupervised on a bedside commode after a CNA, unaware of the supervision requirement, left to assist another resident. The resident activated the call light and waited 21 minutes before self-transferring back to bed, contrary to the care plan instructions for continuous supervision.
Two residents who were frequently incontinent and dependent on staff did not receive timely incontinence care, resulting in prolonged periods in soiled briefs and urine on the floor. Documentation was inconsistent, and staff interviews confirmed delays in care and failure to follow facility protocols for regular checks and assistance.
A resident with sleep apnea and edema received PRN oxygen therapy as ordered, but staff failed to document oxygen administration, tubing changes, or equipment cleaning as required by facility policy. Multiple staff confirmed the resident's regular oxygen use, yet no records were found in the MAR or TAR, and no maintenance schedule was in place.
A resident with chronic pain did not receive prescribed oxycodone on multiple occasions due to delays in obtaining a refill, stemming from communication issues between staff, the clinic, and the pharmacy. The resident reported difficulty with daily activities and refused showers until the medication was reordered. Staff confirmed attempts to refill the prescription in advance, but the process was not completed in time, resulting in missed doses.
A resident with diabetes who sometimes needed help with oral care lost their lower denture after placing it on the bedside table, possibly wrapped in a napkin. Despite staff searching for the denture, it was not found, and the resident was told they were responsible for replacement. The Administrator was not informed of the loss at the time, resulting in a delay in starting the replacement process.
A resident with nicotine dependency and visual impairment, who required staff supervision and a smoking apron, was provided with a visibly moldy apron due to a lack of clean equipment. Staff attempted to clean the apron with an alcohol-based wipe before use, but it still smelled of mold and alcohol. Multiple staff acknowledged the unsanitary condition of the apron and the infection control concern.
A resident with moderate cognitive impairment and on anticoagulant therapy was found with a large, unexplained bruise. Nursing staff documented the injury and initiated a risk management report, but did not notify the State Agency as required for suspected abuse or unexplained injuries.
A resident discharged after a stroke did not have therapy orders signed before leaving the facility, as the physician was unavailable. Although home health services were recommended, the lack of signed orders delayed the start of physical and occupational therapy until the resident saw their primary care physician after discharge.
The facility did not notify the state LTC Ombudsman of discharges for three residents, including individuals with diabetes, stroke, and heart failure, as required. Documentation and discharge forms did not include these residents, and staff confirmed the lack of notification.
The facility failed to maintain sanitary food handling practices. A Cook/Dietary Aide used the same gloves and cutting board after wiping it with a bleach rag, then handled food without changing gloves. The Dietary Manager confirmed that staff are expected to change gloves and use portable cutting boards.
The facility failed to ensure hygienically clean laundry by allowing wet laundry to remain in machines overnight and not rewashing it before drying. Housekeeping staff admitted to these practices, which were confirmed by the Housekeeping Manager.
The facility failed to ensure proper labeling and storage of biologicals and medications, and did not maintain accurate temperature logs for medication storage. Expired vials of tuberculin and insulin were found, and temperature logs were incomplete, placing residents at risk for reduced efficacy of medication and adverse side effects.
The facility failed to maintain clean resident rooms, as evidenced by a resident's room having visible dust and hairs under the bed despite being marked as cleaned. The housekeeping manager acknowledged the issue, and Resident Council notes indicated similar complaints from other residents.
A resident with major depressive disorder and anxiety was verbally abused by an RN who insisted the resident take a shower, making derogatory comments about their hygiene in front of others. The incident was corroborated by multiple staff and another resident, leading to the RN's termination.
A resident purchased a scrub top online for a CNA with the expectation of being reimbursed. The CNA paid only part of the amount owed, and the facility failed to provide documentation of reimbursement to the resident, leading to financial abuse.
A facility failed to provide necessary ROM services and equipment for a resident with contractures, leading to a lack of follow-up on OT recommendations and the resident not participating in a restorative aide program. The resident's condition was not adequately monitored or managed, placing them at risk of worsening contractures and skin breakdown.
A resident with weakness and heart failure fell from a sit-to-stand device due to untrained staff usage. The incident was not properly assessed, documented, or investigated, placing the resident at risk for injuries.
The facility failed to ensure proper oxygen administration and maintenance of oxygen concentrators for two residents. One resident's concentrator filter was not cleaned as ordered, and another resident received oxygen at an incorrect flow rate with a dirty filter.
The facility failed to follow pharmacist recommendations in a timely manner for a resident with major depressive disorder and psychosis. The pharmacist's suggestion to adjust medications was not reviewed and signed by the physician until 19 days later, contrary to the facility's 7-day policy, placing the resident at risk for unnecessary medication administration.
The facility failed to have a dialysis agreement in place for a resident dependent on renal dialysis. Upon request, the Corporate RN confirmed that no agreement was in place.
The facility failed to accurately document medication administration for a resident with hypothyroidism and septic arthritis. The resident's April 2024 MAR and TAR revealed missed documentation for levothyroxine and vancomycin doses. Staff confirmed the medications were administered but not documented, risking inaccurate medical records.
The facility failed to offer a pneumonia vaccine to a resident admitted with depression in August 2023, despite a policy requiring vaccination status assessments within five working days of admission. Staff confirmed the oversight, placing the resident at risk for infections.
Failure to Maintain Emergency Medication Supply and Timely Medication Administration
Penalty
Summary
The facility failed to maintain an on-hand supply of emergency hypoglycemic medication and did not administer anti-seizure medications according to provider orders for two residents. One resident with end stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia, resulting in unresponsiveness and repeated hospitalizations. Despite standing physician orders for glucagon injections in cases of low blood glucose, the facility did not have glucagon available in the emergency kit or on medication carts. Staff confirmed the absence of glucagon, and documentation showed that during several hypoglycemic events, no glucagon was administered, and the resident was instead sent to the hospital for treatment. Another resident with quadriplegia and a traumatic brain injury did not receive anti-seizure and muscle relaxant medications at the times ordered. Medication administration records showed that doses of Baclofen, Levetiracetam, and Klonopin were given several hours late and in close proximity to each other, rather than being spaced out as prescribed. Staff involved in medication administration were unsure of the policy for late medications and did not contact the provider when errors occurred. There was no documentation in the resident's chart indicating that the provider was notified of the medication errors or that any alert charting was completed. Interviews with staff and review of records confirmed that the facility did not follow standing orders for diabetic management and failed to maintain sufficient emergency medication supplies. Additionally, the facility did not ensure timely and appropriate administration of anti-seizure medications, nor did staff seek guidance from the provider when medication errors occurred. These failures resulted in repeated hospitalizations and placed residents at risk for adverse health outcomes.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for multiple residents. Several residents, including those with cognitive impairment, mobility limitations, and incontinence, experienced significant delays in receiving assistance. For example, one resident with memory loss reported waiting approximately 30 minutes for staff to answer the call light on multiple occasions, as confirmed by call light logs and staff interviews. Staff acknowledged that busy times, such as mornings and mealtimes, contributed to delays, with some staff reporting that they could only assist one resident at a time while multiple call lights were active. Another resident with a femur fracture and requiring assistance with activities of daily living waited up to an hour for help with toileting, as documented in a grievance form and corroborated by staff. The resident reported being left on a bedpan for 20 to 30 minutes until the shift changed, and staff confirmed the resident's complaint. Additional residents with conditions such as respiratory failure, kidney disease, and recent fractures also experienced call light response times ranging from 25 minutes to over an hour, leading to episodes of incontinence and discomfort. Call light logs and resident statements consistently indicated that response times exceeded the facility's stated expectation of five to fifteen minutes. Staff interviews, including those with CNAs and the Director of Nursing Services, confirmed awareness of the delays and the expectation for timely responses. However, documentation and direct observation revealed that these expectations were not met, particularly during busy periods. The lack of adequate staffing and delayed responses placed residents at risk for unmet needs and compromised their ability to attain or maintain their highest practicable well-being.
Expired Medications Found in Storage and Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were not expired in multiple storage locations, including the medication storage room, a medication cart, and a treatment cart. During observations, two bottles of Metamucil with an expiration date of 4/2025 were found in the medication storage room, and a bottle of acid reducer 20mg with an expiration date of 5/2025 was found on a medication cart. Additionally, two vials of insulin (Insulin Aspart and Insulin Glargine) with open dates of 7/17/25 were found on a treatment cart, exceeding the facility's policy to discard multi-dose vials within 28 days of opening. Staff interviews confirmed the expectation that expired medications should be destroyed and replaced, and that insulin vials should be discarded 28 days after opening. The Director of Nursing Services acknowledged the presence of expired medications in the storage room, medication cart, and treatment cart, and confirmed the facility's policy regarding the handling of expired medications and insulin vials.
Ice Machine Drain Lacks Required Air Gap
Penalty
Summary
Surveyors observed that the facility failed to maintain an air gap in the drainpipe of the kitchen ice machine, as required to prevent backflow and potential contamination. During two separate observations with the Dietary Manager, the ice machine drainpipe was found inserted directly into a drain hole without an air gap. The Dietary Manager confirmed the absence of flooding in the kitchen for years, but did not address the missing air gap. The Maintenance staff reported that the lack of an air gap had been identified in a work order in July 2025, but the issue was not corrected. The Administrator stated he was unaware of the missing air gap prior to the survey.
Failure to Follow Physician Orders for Medications, Insulin, and Tube Feedings
Penalty
Summary
The facility failed to ensure physician orders were followed for four residents in areas including medication administration, insulin management, and tube feedings. For one resident with heart failure, a fluid restriction was discontinued per physician order with instructions to reinstate it if certain symptoms occurred. However, the facility did not consistently monitor the resident for weight gain, edema, or breathing difficulties as required, and did not clarify with the physician whether monitoring parameters were still necessary after daily weights were discontinued. Another resident with end-stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia and hospitalizations. The facility did not maintain standing orders for glucagon injections, failed to administer glucagon when blood glucose was critically low, and did not ensure glucagon was available in the emergency kit. Additionally, the facility did not follow through with physician orders to enroll the resident in a continuous glucose monitoring program, despite repeated recommendations and hospital discharge instructions. A third resident experienced medication errors when a provider order to decrease insulin dosage was not followed, resulting in the administration of an incorrect dose. The same resident also had a delay in the initiation of an antibiotic order. For a fourth resident with a feeding tube, a provider order for enteral nutrition was incorrectly discontinued, resulting in missed feedings over several days. In each case, staff acknowledged the errors and confirmed that provider orders were not double-checked for accuracy as expected.
Failure to Provide Correct Size Incontinence Products
Penalty
Summary
The facility failed to ensure that a resident with bowel and bladder incontinence consistently received the correct size of incontinence briefs as specified in the care plan. The resident, who was cognitively intact and had a diagnosis of diabetes, reported that the facility often ran out of the required three X size briefs, resulting in the use of smaller, uncomfortable briefs. Staff interviews confirmed that the resident's specific size was regularly back ordered, leading to periods of two to three days approximately every two weeks when the correct size was unavailable. Central Supplies staff acknowledged the ongoing supply issue, and Social Services staff confirmed the resident's complaints and the back order status. The administrator stated that the facility was responsible for ensuring adequate supplies for care-planned needs.
Failure to Notify Family of Resident Hospitalization
Penalty
Summary
The facility failed to notify a resident's family member of a hospitalization, as required. A resident admitted with diabetes experienced multiple episodes of low oxygen saturation, rapid pulse, and diarrhea, which did not improve with interventions, leading to a hospital transfer. The resident's clinical record listed a family member as the first emergency contact, but there was no documentation that this contact was notified of the hospitalization. The resident, who was cognitively intact, stated that her family should be contacted in such situations. The family member confirmed she was not notified and only learned of the hospitalization after the resident returned and called her. The Director of Nursing Services stated that staff did not notify family because the resident was her own responsible party.
Failure to Maintain Comprehensive Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensive and accurately reflected all physician orders and the resident's needs. A resident with diagnoses including heart failure and pain was admitted and had a physician order for weekly skin checks and for administration of apixaban, an anticoagulant, twice daily. The resident's annual MDS indicated moderate cognitive impairment. On one occasion, a nurse was notified that the resident had a long, dark bruise on the underside of the right breast, which the resident could not explain and did not report pain. Staff confirmed that the resident was on anticoagulant therapy and bruised easily. Although the care plan noted anticoagulant therapy and directed staff to report and document abnormalities such as bruising, it was confirmed by the Director of Nursing Services that the physician order for anticoagulant medication was not included in the care plan. The care plan was not updated after the bruise was discovered, despite staff notification and risk management initiation.
Resident Left Unsupervised on Bedside Commode Despite Fall Risk
Penalty
Summary
A resident with a history of left leg fracture, anxiety, and difficulty walking was identified as high risk for falls upon admission. The care plan specified that the resident's call light should always be within reach and that the resident should not be left unsupervised in the bathroom or on the bedside commode. On the morning in question, the resident activated the call light while on the bedside commode, but staff did not respond for 21 minutes. During this time, the resident self-transferred back to bed, as confirmed by both the resident and staff observations. Further investigation revealed that the CNA who assisted the resident onto the bedside commode left to complete a shower for another resident and notified other staff by radio, but was unaware that the resident was not to be left alone on the commode. The Director of Nursing Services confirmed that the resident's care plan required supervision while on the bedside commode. This lapse in following the care plan resulted in the resident being left unsupervised, placing the resident at risk for accidents.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were frequently incontinent and dependent on staff for assistance. One resident, admitted with kidney failure and muscle weakness, was cognitively intact and required help with toileting. Documentation showed inconsistent recording of incontinence care, with some shifts lacking documentation and no refusals noted. The resident reported that it was easier to wear a brief than wait for staff, and described an incident where they soaked through their wheelchair, leaving urine on the floor, due to not receiving timely assistance. Staff interviews confirmed that the resident remained in a soiled state between lunch and dinner without incontinence care, and staff acknowledged being busy and not providing care as scheduled. Another resident, admitted with benign prostatic hyperplasia and lower urinary symptoms, was also cognitively intact and required staff assistance for incontinence care. Documentation indicated inconsistent care and no refusals. A grievance was filed after the resident requested a brief change and did not receive assistance for an hour, resulting in the resident being soaked and urine present on the floor. Staff interviews corroborated the delay in care and the resident's complaint. Facility policy required staff to check on residents every two hours and offer assistance, but this was not consistently followed for these residents.
Failure to Document and Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with diagnoses including sleep apnea and edema. Although a physician ordered PRN oxygen therapy via nasal cannula for shortness of breath, there was no documentation of the start date, oxygen tubing changes, or cleaning of the oxygen concentrator filter. The facility's policy required detailed documentation for oxygen administration, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained no entries regarding the resident's PRN oxygen therapy during the review period. Multiple observations and interviews confirmed that the resident regularly used oxygen, including while sleeping and during various shifts. Staff and therapy personnel also reported the resident's reliance on oxygen. Despite this, there was no documentation of oxygen use or required maintenance procedures, and the Director of Nursing Services confirmed the absence of a tubing and filter cleaning schedule. This lack of documentation and adherence to policy placed the resident at risk for unmet respiratory needs.
Failure to Ensure Timely Refill of Pain Medication
Penalty
Summary
A resident with a diagnosis of chronic pain was admitted to the facility and had an order for oxycodone to be administered every eight hours as needed for pain. The resident's medication administration record (MAR) and order summary reports indicated that oxycodone was to be refilled by a specific physician. On several occasions, the resident did not receive the prescribed oxycodone due to issues with obtaining a timely refill. Progress notes documented that the pharmacy placed the medication on hold pending clarification of the prescribing physician, and staff were unable to use the emergency supply. As a result, the resident missed multiple doses of oxycodone. The resident expressed difficulty participating in daily activities and getting out of bed without the pain medication and refused showers until the medication was reordered. Staff interviews confirmed that attempts were made to refill the prescription at least a week in advance, but delays occurred due to communication issues with the clinic and pharmacy. The Director of Nursing Services acknowledged the need for a system to ensure timely medication refills. The failure to provide the prescribed pain medication as ordered resulted in the resident experiencing periods without adequate pain control.
Failure to Timely Replace Lost Denture
Penalty
Summary
A resident with diabetes was admitted to the facility and, according to their Activities of Daily Living (ADL) report, sometimes required assistance with oral care. The resident reported that the facility lost their lower denture after placing it on the bedside table, possibly wrapped in a napkin while applying adhesive. When the resident later attempted to eat a snack, the lower denture could not be found. Facility staff, including CNAs, searched the bedding, laundry, and dietary department but were unable to locate the missing denture. Documentation showed that the Director of Nursing Services (DNS) informed the resident they were responsible for the care of their dentures and would need to pay for a replacement. The Administrator stated they were not notified of the missing denture at the time it was lost, and as a result, the process to replace the denture was not initiated promptly. This failure to ensure timely replacement of the lost denture constituted a deficiency in providing or obtaining necessary dental services for the resident.
Failure to Provide Clean Smoking Equipment
Penalty
Summary
The facility failed to provide clean and sanitary smoking equipment for a resident who was admitted with nicotine dependency and visual impairment, and who required staff supervision and the use of a smoking apron while smoking. On the day of the incident, staff reported that no clean smoking aprons were available, and the only remaining apron was visibly moldy. Staff expressed reluctance to use the moldy apron but ultimately attempted to clean it with an alcohol-based wipe before placing it on the resident. The apron still smelled of mold and alcohol after cleaning, and staff acknowledged that residents should not be wearing moldy smoking aprons. The lack of clean equipment and the use of a moldy apron were confirmed by multiple staff members, including the Maintenance Director, as an infection control concern.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin for one resident who was on anticoagulant medication and had moderate cognitive impairment. The resident was admitted with diagnoses including heart failure and pain, and had physician orders for weekly skin checks and anticoagulant administration. On a specified date, a nurse was notified of a long, dark bruise on the underside of the resident's right breast, but the resident was unable to explain how the bruise occurred and did not complain of pain. There was no documentation indicating that staff notified the State Agency about the bruise. Staff confirmed that a risk management report was initiated, but the incident was not reported to the State Agency as required.
Failure to Ensure Timely Therapy Orders at Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that therapy orders were in place for a resident being discharged after a stroke. The resident was discharged according to the family's wishes, despite the therapy department recommending two additional weeks of therapy. Although a referral to a Home Health Agency was submitted, the necessary physical therapy and occupational therapy orders were not signed before discharge because the physician was not present in the facility. As a result, the home health provider did not receive the therapy orders until the resident visited their primary care physician after discharge, causing a delay in the initiation of home health therapy services.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman's office of discharges for three out of four sampled residents who were reviewed for discharges and hospitalizations. For one resident with diabetes, progress notes indicated a hospital admission, but there was no documentation that the LTCO was notified of the discharge. This was confirmed by the Regional Director of Quality Assurance. Another resident with a history of stroke was discharged, but the Ombudsman Notice of Residents Discharge form did not include this resident, and there was no documentation of LTCO notification, as verified by the same staff member. A third resident, admitted with acute respiratory failure with hypercapnia and chronic systolic heart failure, was also admitted to the hospital, but their name was not found on the Ombudsman Notice of Residents Discharge forms for the relevant months. The Social Services staff stated that a monthly fax was sent to the LTCO office listing all discharges, but no additional information was provided. Attempts to contact the LTCO office were unsuccessful, and the DNS stated that the LTCO office would be expected to be notified monthly for hospitalizations and immediately for deaths.
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. Staff 26, a Cook/Dietary Aide, was seen cutting a hamburger patty with gloved hands on a cutting board attached to the steam table. After placing the patty on a plate, Staff 26 used a rag from a red bleach bucket to wipe the cutting board and knife, leaving the cutting board wet. Without changing gloves, Staff 26 then grabbed a skinned baked potato and cut it on the same wet cutting board with the same knife. When questioned, Staff 26 admitted to not knowing the appropriate drying time after wiping a surface and acknowledged forgetting to change gloves after using the rag. The Dietary Manager, Staff 27, stated that staff are expected to change gloves and perform hand hygiene after touching potentially contaminated surfaces and to use portable cutting boards, changing them as needed.
Failure to Maintain Hygienically Clean Laundry
Penalty
Summary
The facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection. Staff 22 and Staff 23, both from housekeeping, admitted to leaving wet laundry in the washing machine overnight and transferring it to the dryer the next morning without rewashing it. Additionally, Staff 23 mentioned placing damp laundry in a basket and covering it when the dryer cycle was not completed by the end of her shift, and then finishing the drying process the next morning. These practices were acknowledged by Staff 19, the Housekeeping Manager, who confirmed that the staff did not follow the standards required to produce hygienically clean laundry.
Failure to Ensure Proper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of biologicals and medications, as well as maintaining accurate temperature logs for medication storage. During an observation, two vials of tuberculin were found to be opened and expired, with one vial having an illegible date and the other dated beyond the manufacturer's recommended 30-day discard period. Staff acknowledged the expired vials. Additionally, the medication refrigerator temperature logs were found to be blank on several dates, indicating a failure to monitor and record the storage temperatures as required. Staff confirmed the missing temperature logs during the observation. Further observations revealed that the treatment cart for the 100 hall contained an expired Admelog insulin vial and an expired Novolog insulin vial, both of which were past the manufacturer's recommended 28-day usage period after opening. Staff acknowledged the expired insulin vials. These deficiencies in labeling, storage, and temperature logging placed residents at risk for reduced efficacy of medication and potential adverse side effects.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to ensure resident rooms were cleaned adequately, as evidenced by the condition of one resident's room. Resident 9, who was admitted with diagnoses including respiratory failure and heart failure, had a room that was observed to have a visible layer of white and gray dust and hairs underneath the bed over a period of several days. Despite the Daily Cleaning Check-Off form indicating that the room was cleaned, the housekeeping manager acknowledged the presence of dust and deemed it unacceptable. Resident Council notes also indicated that residents had reported issues with dirty floors, further highlighting the deficiency in maintaining a clean environment.
Verbal Abuse of Resident by RN
Penalty
Summary
The facility failed to protect Resident 20 from verbal abuse by Staff 24 (RN). Resident 20, who was admitted with diagnoses including major depressive disorder and anxiety disorder, was cognitively intact and independent with bathing, requiring only setup help. On the morning of 3/31/24, Staff 24 approached Resident 20 about taking a shower, which the resident refused, stating they would shower after church. Staff 24 confronted Resident 20 again after church, insisting that the resident needed to shower because they 'stunk.' This confrontation occurred in front of other staff and residents, causing Resident 20 to feel upset and humiliated. Multiple staff members and another resident corroborated the incident, stating that Staff 24 yelled at Resident 20 and made derogatory comments about their hygiene. On 4/29/24, Resident 20 recounted the incident, stating that Staff 24's comments made them feel terrible. Staff 30, who was present during the second confrontation, confirmed that Resident 20 was visibly upset and crying after Staff 24 refused to leave the room. The facility's investigation, completed on 4/2/24, confirmed that Staff 24 had verbally abused Resident 20, leading to Staff 24's termination. Staff 2 (DNS) acknowledged the verbal abuse and confirmed the termination of Staff 24 following the investigation.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of personal funds by a CNA. Resident 302, who was alert and oriented, purchased a scrub top online for Staff 34 with the expectation of being reimbursed. Staff 34 paid only $20 of the $34 owed and continued to wear the scrub top, causing Resident 302 to feel disrespected. Despite the facility's assurance that Resident 302 would be reimbursed, there was no receipt or evidence of reimbursement provided to the resident. Interviews and record reviews revealed that Staff 34 was terminated, but the facility did not provide documentation of reimbursement to Resident 302. The Business Office Manager confirmed the absence of a receipt for the reimbursement, and the Corporate RN acknowledged the misappropriation of funds. The facility's policy stated that staff should not accept gifts or money from residents, yet this policy was not adhered to in this instance, leading to the financial abuse of Resident 302.
Failure to Provide ROM Services and Equipment for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with contractures received the necessary range of motion (ROM) services and equipment to prevent further decrease in ROM and skin breakdown. The resident, who was admitted with diagnoses including quadriplegia and rheumatoid arthritis, had a care plan from a previous facility indicating the use of palm protectors for contractures in both hands and legs. However, the current care plan did not include any mention of the resident's contractures or the use of a palm device. An occupational therapy (OT) evaluation recommended the use of a splint and ROM exercises, but no follow-up was conducted, and the resident did not receive the recommended care or participate in a restorative aide (RA) program after returning from the hospital. The resident expressed interest in wearing palm protectors and participating in the RA program, but no referral was made, and the resident's condition was not adequately monitored or managed by the facility staff. Observations revealed that the resident's hands were contracted, and no palm device was in use. Interviews with staff confirmed that the resident was not on the RA list, and no RA referral was completed. The OT evaluation was acknowledged but not acted upon, and the resident's fragile skin and contractures required extra monitoring that was not provided. The lack of follow-up and coordination among staff led to the resident not receiving the necessary ROM services and equipment, placing the resident at risk of worsening contractures and skin breakdown.
Failure to Assess and Prevent Falls
Penalty
Summary
The facility failed to assess falls and provide treatment to prevent falls for a resident admitted in 2022 with diagnoses including weakness and heart failure. The resident, who was cognitively intact, reported falling out of a sit-to-stand device several months prior. However, no fall assessments or incident reports were found in the clinical record. Staff 2 (DNS) initially denied the fall, stating the resident was assisted to the floor, and no assessment was completed. A written statement from Staff 20 (CNA) confirmed the incident but did not include the date. The resident and a family member both described the fall, indicating the resident fell to the floor and was later lifted back to bed using a mechanical lift. Staff 14 (Director of Rehab) acknowledged that only one staff member was trained to use the sit-to-stand device with the resident, but other untrained staff had used it during the incident. Further investigation revealed that Staff 21 (LPN) had started an incident report on the date of the fall but did not complete it, and it was later struck out by Staff 2 due to incorrect documentation. Staff 8, who was present during the fall, confirmed that the resident's legs became wobbly during the transfer, leading to the fall. Staff 2 admitted that the fall was not reported or investigated properly, and the involved staff did not receive appropriate training for using the sit-to-stand device with the resident. The lack of proper assessment, documentation, and training placed the resident at risk for falls and injuries.
Failure to Maintain Oxygen Therapy and Equipment
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered and to maintain oxygen concentrators for two residents. Resident 36, admitted in August 2023 with chronic respiratory failure with hypercapnia, was observed using an oxygen concentrator with a dusty external filter from April 29, 2024, through May 1, 2024. Despite a physician's order to clean the filter every Tuesday night, the filter remained dirty. Staff 21, who was responsible for cleaning the filter, did not respond to a phone call, and Staff 2 acknowledged the filter was not clean. Resident 251, admitted in February 2024 with acute respiratory failure with hypoxia and dementia, was observed using an oxygen concentrator with a nasal cannula at a flow rate of three liters, contrary to the physician's order of one to two liters per minute as needed. The external filter on Resident 251's concentrator was also dusty, and the 4/2024 TAR did not specify when the filter should be cleaned. Staff 12 confirmed the resident used oxygen as needed, and Staff 2 acknowledged the physician's order was not followed and the filter was not clean.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to follow pharmacist recommendations in a timely manner for a resident reviewed for unnecessary medications. The resident, admitted in 2023 with diagnoses including major depressive disorder and psychosis, had a pharmacist recommendation on 1/16/24 to adjust their medication regimen. The recommendation suggested increasing nortriptyline for depression and decreasing aripiprazole for psychosis. However, the physician did not review and sign off on the recommendation until 2/4/24, 19 days later. The facility's expectation was for such recommendations to be reviewed and signed within 7 days. This delay in addressing the pharmacist's recommendations was acknowledged by the Director of Nursing Services (DNS) and was not in compliance with the facility's policies, placing the resident at risk for unnecessary medication administration.
Lack of Dialysis Agreement for Resident
Penalty
Summary
The facility failed to have a dialysis agreement in place for a resident who was dependent on renal dialysis. The resident was admitted to the facility in April 2024. On April 30, 2024, a copy of the dialysis agreement was requested from the Corporate RN. Later that day, the Corporate RN confirmed that the facility did not have a dialysis agreement in place for the resident.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to accurately document medication administration for a resident admitted in March 2024 with diagnoses including hypothyroidism and septic arthritis. A physician order dated April 1, 2024, instructed staff to administer one tablet of levothyroxine 50mcg daily at 5:00 AM. However, a review of the resident's April 2024 Medication Administration Record (MAR) revealed that the scheduled dose on April 26, 2024, was not documented as administered. Staff 3 (RNCM) confirmed that the documentation was inaccurate and that Staff 32 (LPN) had administered the medication but forgot to document it in the clinical record. Additionally, a physician order dated April 22, 2024, instructed staff to administer vancomycin solution 250 ml intravenously twice daily at 11:00 AM and 11:00 PM. A review of the resident's April 2024 Treatment Administration Record (TAR) showed that the scheduled dose on April 26, 2024, at 11:00 AM was not documented as administered. Staff 3 (RNCM) confirmed that the documentation was inaccurate and that Staff 33 (LPN) had administered the medication but forgot to document it in the clinical record. These documentation failures placed the resident at risk for inaccurate medical records.
Failure to Offer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that residents were offered a pneumonia vaccine, as evidenced by the case of one resident who was admitted in August 2023 with a diagnosis of depression. A review of the resident's clinical record revealed that the resident did not receive a pneumonia vaccine and there was no indication that the vaccine was offered upon admission. The facility's policy, dated March 2022, required assessments of pneumococcal vaccination status within five working days of admission. However, this policy was not followed in the case of the resident. Staff confirmed that the resident was not offered the pneumonia vaccine upon admission, which placed the resident at risk for infections.
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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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