Avamere Rehabilitation Of Eugene
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 2360 Chambers Street, Eugene, Oregon 97405
- CMS Provider Number
- 385053
- Inspections on file
- 25
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Eugene during CMS and state inspections, most recent first.
A resident with acute respiratory failure and heart failure had a documented Full Code status and a POLST specifying Attempt Resuscitation/CPR and Full Treatment. During night rounds, two CNAs found the resident not breathing, cool to the touch, with yellow skin and no pulse, but did not initiate CPR or call a code blue, instead going to notify an LPN. The LPN assessed the resident, confirmed absence of vital signs, noted the body was cold with mottling and no rigor mortis, and contacted the DNS, physician, and 911 for the coroner’s number, but did not start CPR or activate a code blue. No lifesaving measures were attempted despite facility policy requiring CPR for unresponsive residents without a valid DNR and the resident’s clearly documented full code status, leading surveyors to cite Immediate Jeopardy and substandard quality of care.
A resident with respiratory failure and pneumonia, who was Full Code and not on hospice, was found during routine rounds and suspected to be deceased. Nursing staff assessed the resident, noted there was no rigor mortis, confirmed death, and did not initiate a code blue or any resuscitation efforts despite the resident’s Full Code status. The facility later treated this as a potential neglect incident but did not report it to the State Agency within the required two-hour timeframe, as confirmed by the regional QA director.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
Surveyors identified unsanitary conditions in the laundry room, including a longstanding hole in the wall near washing machines, brown standing water behind the machines, and a black substance along the wall and floor. The housekeeping director reported that maintenance had been notified weeks earlier but repairs had not been made and could not identify the black substance. A cart of clean linen was placed near the standing water, and a blanket was observed partially submerged in the dirty water, which a laundry aide confirmed. The administrator later verified the standing water and black substance and was informed that water had been leaking onto the floor whenever the machines were used for several weeks.
A cognitively intact resident with heart failure and kidney disease reported that a CNA/CMA spoke meanly, was rough, and treated them like a “bad dog,” and expressed fear of retaliation and discharge. An LPN acknowledged hearing this CNA/CMA be rude to the resident and to others, and stated that other staff had observed similar behavior, but she did not report it to management. The Administrator and DNS were later informed of the allegation and stated that staff are expected to notify them, the provider, and family when a resident feels abused, yet the allegation was not reported to the State Survey Agency as required.
Two residents experienced deficiencies in accident prevention when staff did not follow their care plans. One resident with dementia and a history of rolling out of bed was repeatedly observed in bed without a required fall mat properly placed on one side, despite a care plan directing padded mats on both sides whenever the resident was in bed. Another resident with stroke-related weakness, care planned for two-person assistance with transfers using a FWW, was transferred by a single CNA after a shower without reviewing the care plan, during which the resident’s legs weakened and the resident slid or fell to the floor. Staff and leadership later confirmed that both residents were care planned for these specific safety measures and that staff were expected to follow and review care plans.
A resident with a surgical wound did not receive wound care as ordered by the physician, including failure to implement dressing changes, monitor the wound, schedule a follow-up appointment, and remove sutures as directed. The omission of these orders and lack of documentation led to the development of cellulitis and required antibiotic treatment.
A resident with Parkinson's disease and a history of falls was identified as an elopement risk but managed to exit the facility twice. The facility failed to conduct timely investigations or implement appropriate interventions after the initial incident, allowing the resident to leave the building unattended on a second occasion.
The facility failed to follow proper infection control procedures, leading to a COVID-19 outbreak among residents and staff. Observations revealed staff not using appropriate PPE and neglecting hand hygiene. Additionally, inappropriate cohorting of residents and a lack of communication to families about the outbreak were noted. The infection preventionist acknowledged these deficiencies, highlighting insufficient staff training on infection control protocols.
The facility failed to update care plans for four residents, leading to potential unmet care needs. A resident with multiple sclerosis had outdated catheter flush orders, another with heart disease did not have updated fall prevention measures, a third resident's anticoagulant medication was not included in their care plan, and a bedbound resident's fall mats were not documented. These oversights were acknowledged by an LPN.
The facility failed to follow up on critical care needs for several residents, including improper handling of a urine sample for a resident with MS, incomplete neurological assessments for a resident with heart disease, lack of wound assessments for a post-surgery resident, and inadequate pain management for a hospice resident. Additionally, a resident with spinal stenosis did not receive a CT scan due to a lack of follow-up on MRI alternatives.
The facility did not ensure CNAs received the required 12 hours of annual training. Three staff members, hired in 2016, 2021, and 2022, were found lacking in their training hours. This was confirmed by the DNS during a review.
A resident with anxiety disorder and depression was prescribed Lexapro, but the facility failed to provide information on the risks and benefits of the medication. This lack of documentation was confirmed by the DNS, indicating a deficiency in informing the resident about their treatment.
A resident with COPD was found with inhaler medications on their bedside table without an assessment for self-administration in their medical record. An LPN confirmed that the resident had not been assessed for self-administration, which should have been done to ensure safe medication practices.
A resident admitted with stroke and anxiety was not provided with the facility's Resident Handbook, which included rules about compact refrigerators. Despite being cognitively intact, the resident was confused about the denial of a refrigerator request, as they were unaware of the official rules. The Administrator in Training confirmed that residents had not received the handbook since March.
The facility failed to document advance directives for two residents, one with a hip fracture and another with congestive heart failure. Despite indications that Resident 12 had an advance directive, it was missing from their electronic record. Resident 18 expressed a desire to complete an advance directive, but none was documented. The Social Services Director confirmed these omissions.
The facility failed to notify family members of significant changes for two residents. One resident with MS was hospitalized without informing the emergency contact, and another resident with dementia was moved to a different room without family notification. The facility acknowledged these communication lapses.
A resident with palliative care and schizophrenia experienced an unhomelike environment due to persistent cleanliness issues in their room. Observations revealed fall mats with debris and dirty washcloths in the sink, which were not addressed by staff. A Regional Nurse Consultant confirmed the room's condition.
The facility failed to maintain good grooming and hygiene for two residents receiving hospice services. One resident, fully dependent on staff, was found with unkempt hair, dirty fingernails, and food debris, while another resident had long, dirty fingernails. A caregiver reported inadequate ADLs care for the first resident, and an LPN confirmed the deficiencies for both residents.
A facility failed to investigate a new facility-acquired stage 3 pressure ulcer in a resident with hemiplegia. The ulcer, located on the sacrococcygeal area, was documented but not investigated, leading to further skin damage. This oversight placed residents at risk for worsening pressure ulcers.
Two residents in a facility were at increased risk for UTIs due to inadequate care. One resident with a urinary catheter did not receive scheduled flushes due to a lack of sterile solution, and the facility failed to notify the physician for alternatives. Another resident with dementia and a history of UTIs suffered from poor perineum hygiene due to insufficient staff training and communication about their unique needs.
The facility failed to maintain respiratory equipment for three residents, leading to potential respiratory issues. A resident with COPD had nebulizer equipment stored unsanitarily among dirty items, with no documentation of care. Another resident with pneumonia had nebulizer equipment improperly stored with bedding, also lacking documentation. A third resident with sleep apnea had a CPAP machine with dirty tubing and no care plan interventions documented. Staff confirmed the improper storage and lack of record-keeping.
A resident with PTSD and anxiety was not provided with person-centered interventions, leading to a risk of re-traumatization. The care plan included non-personalized interventions, and the resident's request for counseling was not followed up. Staff interviews revealed that the resident's disruptive nightmares were not documented, and no PTSD assessment was completed upon admission. The facility lacked formal training for PTSD, resulting in inadequate evaluation and documentation of the resident's condition.
The facility did not complete annual performance reviews for three CNAs. Two CNAs had not been reviewed since 2022, and one CNA had no review documented since her hire. This was confirmed by the DNS.
A resident with atrial fibrillation was prescribed apixaban, an anticoagulant, but the facility failed to monitor for adverse side effects like bleeding and bruising. Despite a physician's order, there was no care plan or evidence of monitoring in the resident's medical record. An LPN confirmed the lack of monitoring.
The facility failed to implement gradual dose reductions and monitor psychotropic medications for two residents, risking adverse reactions. One resident with anxiety and depression was not monitored for medication effects, and their triggers were undocumented. Another resident had their Wellbutrin dosage increased without justification or recent GDR attempts, despite no mood changes. Staff acknowledged these deficiencies.
A treatment cart on the Shasta Unit was observed to be unlocked, posing a risk to residents. The cart was located in an alcove, partially obscured from the nurse's station, and was not secured despite staff passing by multiple times. An LPN, unaware of the situation, confirmed the cart should have been locked.
A resident with kidney failure was served a high-salt meal instead of their prescribed low-salt diet due to a lack of training and menu planning in the facility. The cook was unaware of the need for alternative options, and the dietary manager admitted that no alternative items were purchased since a new menu system began.
The facility failed to provide meals according to resident preferences, affecting two residents with specific dietary needs and preferences. One resident with anemia and acute kidney failure often did not receive ordered meals, while another with a history of stroke received disliked foods despite documented preferences. The Dietary Manager acknowledged issues with the new menu system and tray ticket accuracy.
The facility failed to ensure residents understood arbitration agreements, affecting three cognitively intact residents. Despite reviewing the agreements during admission, Staff 9 did not verify residents' comprehension post-signing, leaving them uninformed of their legal rights.
A resident with multiple sclerosis was given antibiotics for a possible UTI despite lab results indicating no need for a culture. The antibiotics were continued without documented rationale, as confirmed by an LPN, risking the development of drug-resistant organisms.
The facility failed to document and administer immunizations properly for three residents, including those with chronic conditions like congestive heart failure and COPD. One resident lacked consents for COVID-19 vaccinations, another was not offered a pneumonia vaccine, and a third received a COVID-19 booster without documented consent. The Administrator in Training could not locate the necessary records, highlighting deficiencies in the facility's vaccination protocol.
The facility failed to ensure call lights were accessible for two residents, leading to unmet needs. One resident with hemiplegia had a call light hanging off the bed, out of reach, despite calling for help. Another resident, bedbound and at moderate fall risk, had a call light in a dresser drawer, inaccessible. Staff confirmed the inaccessibility, and the LPN Resident Care Manager acknowledged the requirement for call lights to be within reach.
A resident in a LTC facility reported a HIPAA violation by a staff member who discussed the resident's preferred name and financial situation, including foreclosure, during a bus trip. This conversation was overheard by another resident, causing distress. An investigation confirmed the violation, leading to increased anxiety for the resident.
The facility failed to protect the privacy of two residents, leading to potential psychosocial harm. One resident's discharge location was disclosed to unauthorized family members, while another resident experienced a HIPAA violation when a staff member inappropriately discussed personal and financial matters during a bus ride. These incidents were acknowledged by the facility's Administrator in Training and confirmed by witnesses.
A resident suffered burns to the mouth after being served extremely hot tea by a CNA, who failed to check the temperature before serving. The resident experienced significant pain and discomfort for two days. The facility's investigation confirmed neglect, as staff had been trained to ensure beverages were not too hot before serving.
A resident suffered burns from hot tea served by a staff member, leading to a substantiated neglect incident. The facility failed to report the incident to the State Agency within the required two-hour timeframe, as the report was delayed until the following day.
The facility failed to implement comprehensive care plans for three residents, leading to unmet care needs. A resident with diabetes lacked a care plan for diabetic management, another high-risk for wandering had no interventions for elopement, and a hospice resident's care plan omitted hospice services. These deficiencies were acknowledged by staff.
A resident, admitted after spinal surgery, was placed in rooms with windows that had broken locking devices, allowing them to be opened despite the use of locks. This issue was confirmed by a complainant and verified by maintenance staff, who were unaware of the problem, indicating a failure to maintain a secure environment.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide CPR in accordance with a resident’s documented full code status. The facility’s Emergency Procedure CPR policy, initiated in 2001, required staff trained in CPR to initiate resuscitation on unresponsive residents who were not breathing unless there was a valid DNR order or clear signs of irreversible death such as rigor mortis. The policy further specified that if a resident’s DNR status was unclear, CPR should be started and continued until a DNR was confirmed. Resident 3 had been admitted with diagnoses including acute respiratory failure and heart failure and had a care plan and POLST on file indicating Full Code/Attempt Resuscitation and Full Treatment, including use of intubation, advanced airway interventions, mechanical ventilation, and transfer to hospital or ICU if indicated. On the night of the incident, a CNA (Staff 5) documented last vital signs for the resident at approximately 10:45 PM, with oxygen saturation of 92% on one liter of oxygen. At 2:00 AM, the resident was observed sleeping, breathing, and with a dry brief. Around 4:00 AM, Staff 5 and another CNA (Staff 8) entered the resident’s room and observed that the resident was not breathing, had yellow skin color, was cool to the touch, and had no palpable pulse. Both CNAs concluded the resident was deceased and went to notify the LPN (Staff 4) instead of initiating CPR or calling a code blue, despite having recent CPR training and later stating that, in retrospect, they would have started CPR and called for a code blue. When Staff 4 (LPN) entered the room, she assessed the resident and found no pulse, blood pressure, or respirations, noted the body was cold, with some mottling on the lower legs, pale/yellowish skin color, and no rigor mortis. Staff 4 did not initiate a code blue or CPR and instead contacted the DNS (Staff 2) and the physician, and then called 911 to obtain the coroner’s phone number. No lifesaving measures were attempted by any staff, despite the resident’s documented full code status and the facility policy requiring CPR in the absence of a valid DNR or signs of irreversible death. The DNS later stated she expected staff to call a code blue immediately, start CPR, call 911, and verify the resident’s code status. Surveyors determined that the facility failed to provide CPR according to the resident’s code status, placing all residents with full code status at risk and constituting substandard quality of care, with the noncompliance cited as Immediate Jeopardy and Past Noncompliance.
Removal Plan
- Administrator, DNS and nursing staff would be re-educated on the code blue process, how to locate a resident's code status in PCC and the POLST on file, and the importance of following individual resident care plans and orders.
- Resident code status would be cross-referenced with the PCC order, POLST scanned in binder, care plan, and resident dashboard.
- DNS or designee would monitor resident code status preferences for new admissions/returning admissions from hospitalizations.
- DNS or designee would audit code status for all new admissions and readmissions from hospitalization or ED visits, and share audit results with the QAPI committee to ensure substantial compliance is maintained.
- DNS or designee would complete a mock code.
- DNS or designee would complete mock codes.
Failure to Timely Report Alleged Neglect Involving Lack of CPR for Full Code Resident
Penalty
Summary
The facility failed to timely report an allegation of potential neglect related to CPR to the State Agency for one resident. The resident was admitted in February 2026 with diagnoses including respiratory failure and pneumonia and had a Full Code status, was not on hospice, and therefore was to receive CPR if found unresponsive. According to the facility’s investigation dated six days after the resident’s death, staff found the resident during routine rounds and suspected the resident was deceased, notified the nurse, and the nurse confirmed the resident was deceased. The investigation documented that at the time of the nurse’s assessment the resident did not have rigor mortis, yet the nurse did not initiate a code blue or any resuscitation interventions despite the Full Code status. The incident, which occurred on an identified date, was not reported to the State Agency until a later identified date, and the Regional Director of Quality Assurance confirmed that the facility did not report the incident within the required two-hour timeline. This failure to timely report the allegation of potential neglect involving the lack of CPR initiation for a Full Code resident constituted the deficiency identified by surveyors.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Unsanitary Laundry Room Conditions and Contaminated Clean Linen
Penalty
Summary
The facility failed to ensure laundry was cleaned and sorted in a safe manner when surveyors observed a hole in the wall next to the washing machine and a large pool of brown, dirty standing water behind two washing machines and a clean linen cart in the laundry room. Along the baseboard of the wall behind the machines, a black substance extended about an inch up the wall and an inch onto the floor. The Housekeeping Director stated the hole in the wall had been present for some time, that maintenance had been notified of the standing water a few weeks earlier but it had not yet been repaired, and did not know what the black substance was. Later observation showed a cart of clean linen and laundry near the standing water, with a blanket from the cart partially in the water, which the Laundry Aide confirmed had touched the water. The Administrator subsequently confirmed the presence of standing water and the black substance on the wall and floor and learned from the Laundry Aide that the water on the floor had been occurring for the last three weeks when the washing machines were in use, and that the water and some of the black substance had just been cleaned up. No specific residents or their medical conditions were mentioned in the report.
Failure to Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the State Survey Agency for one cognitively intact resident. The resident, admitted with diagnoses including heart failure and kidney disease, had a care plan dated 12/24/25 indicating that if the resident made accusatory comments about family or staff not treating them well or denying medications, staff were to alert the nurse to assess for signs and symptoms of a urinary tract infection. On 1/12/26 at 2:13 PM, the resident reported that a CNA/CMA had abused them, stating the staff member spoke meanly, was rough, and treated them like a “bad dog.” The resident also expressed fear of retaliation from the staff member and fear of being discharged from the facility. At 2:16 PM the same day, an LPN stated that the staff member identified by the resident was a CNA/CMA and acknowledged hearing this staff member be rude to the resident. The LPN further reported that this staff member’s demeanor changed when rushed or having a bad day and that she had heard the staff member be rude to other residents, with other staff also observing this behavior, but she did not report it to management. At 2:42 PM, the Administrator and DNS were notified that the resident felt abused by this staff member, and the Administrator indicated this was the first time he had heard of the allegation. At 2:52 PM, the Administrator and DNS stated their expectation that when a resident feels abused by a staff member, staff must notify them immediately, notify the provider and family, and ensure resident safety; however, the allegation had not been reported to the State Survey Agency as required.
Failure to Follow Care Plans for Fall Mats and Two-Person Transfers
Penalty
Summary
Surveyors identified that the facility did not consistently follow an established fall-prevention care plan for a resident with dementia and a history of rolling out of bed. The resident’s care plan, initiated in early December, required padded fall mats on both sides of the bed whenever the resident was in bed. On multiple observations over several days in January, the resident was seen in bed without a fall mat on the left side, or with the left fall mat placed away from the bedside or folded and leaning against the foot of the bed. A CNA confirmed the resident was at risk for falls and should have fall mats on the floor next to the bed while in bed, and a LPN Resident Care Manager stated the resident had previously rolled out of bed and was care planned for fall mats on both sides, with the expectation that staff follow the care plan. Surveyors also found that staff failed to follow a care plan requiring two-person assistance for transfers for a resident with a history of stroke and weakness. The resident’s care plan documented a need for two-person assistance with transfers using a front-wheeled walker. A fall investigation from July showed that a CNA, after providing a shower, assisted the resident to stand and transfer using the walker without a second staff member, during which the resident’s legs weakened, balance was lost, and the resident slid or fell to the floor. The CNA stated she did not review the care plan before performing the transfer, and the investigation and root cause analysis identified that the resident was a two-person assist and the CNA did not check the care plan. The LPN notified of the incident and facility leadership later acknowledged that the resident was care planned as a two-person transfer and that staff were expected to review the care plan before providing care.
Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A resident with an open fracture of the left lower leg and diabetes was admitted to the facility with specific hospital discharge instructions for surgical wound care, including the use of a honeycomb dressing, monitoring for excessive drainage, removal of staples after two weeks, and scheduled follow-up with the surgeon. Upon review, it was found that the resident's admission nursing database did not include information about the surgical site or wound care, and the medication and treatment administration records lacked any wound care or monitoring orders for the first two weeks after admission. The resident missed the required follow-up appointment, and the prescribed dressing protocol was not implemented or documented during the initial seven days post-admission. Subsequently, the resident developed new slough, increased redness, and drainage at the surgical site, leading to a diagnosis of cellulitis and the initiation of antibiotics. Further review showed that even after wound care orders were eventually entered, there were missed wound care treatments on specific days. Staff interviews confirmed that the wound was not checked or monitored upon admission, the dressing orders were not transcribed, the follow-up appointment was missed, and the sutures were not removed as ordered by the physician.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure interventions to prevent a resident's elopement were in place, which placed residents at risk for a lack of a safe environment. Resident 315, who was admitted with diagnoses including Parkinson's disease and a history of repeat falls, was identified as an elopement risk with impaired safety awareness. Despite a care plan indicating the resident should not leave the facility unattended, the resident was observed exiting the facility on two occasions. On the first occasion, the resident was seen exiting through the back door and was brought back inside with assistance. On the second occasion, the resident was found outside the facility near a stop sign after hiding their wheelchair in the courtyard and exiting through a different back door. The facility did not conduct an investigation following the first incident on 9/16/24, as the resident did not leave the facility grounds. Staff were aware of the resident's exit-seeking behavior, but no investigation was initiated until after the second incident on 9/28/24. The lack of timely investigation and implementation of appropriate interventions contributed to the resident's ability to leave the building unattended. Staff acknowledged that interventions related to the resident's ability to elope were not discovered and implemented due to the absence of investigations after the initial incidents.
Inadequate Infection Control Leads to COVID-19 Spread
Penalty
Summary
The facility failed to adhere to appropriate infection control procedures, resulting in the spread of COVID-19 among residents and staff. Upon entrance, surveyors were informed of a COVID outbreak involving four staff and five residents, yet there was no signage indicating the outbreak. Observations revealed multiple instances of staff failing to use proper personal protective equipment (PPE) and neglecting hand hygiene protocols. For example, a CNA entered a COVID-19 precaution room without eye protection, and another staff member failed to wash hands with soap and water after exiting a room on enteric contact precautions. The facility also demonstrated inappropriate cohorting of residents, as evidenced by the placement of a resident suspected of having clostridium difficile with another resident before confirmation of the infection. This action increased the risk of spreading the infection. Additionally, the facility was out of hand sanitizer for a week, further compromising infection control efforts. Staff were observed not following proper procedures for donning and doffing PPE, and there was a lack of communication to family members about the outbreak. The infection preventionist acknowledged the deficiencies in infection control practices, including improper PPE usage and inadequate hand hygiene. Staff training on infection control procedures was insufficient, as demonstrated by a staff member who was not aware of the need to change masks after exiting a COVID-19 precaution room. The facility's failure to implement timely and effective infection control measures placed residents at risk for the continued spread of infectious diseases.
Removal Plan
- The DNS and Administrators were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual.
- The Infection Preventionist was placed on suspension due to the enormity of the deficiencies.
- The new Infection Preventionist was educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual and skills demonstrated.
- New Infection Preventionist will be educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual upon hire.
- All staff were educated on the COVID 19 Policy, Outbreak Checklist and COVID 19 Infection Control Manual for continued compliance of these policies, with emphasis on proper PPE usage and hand hygiene for each type of infection.
- All staff will wear N95 masks while in resident care areas, and in COVID positive rooms will wear a N95 mask, gown, sanitized or disposable goggles and gloves when providing direct patient care and remove all these items before they leave COVID positive room and a new N95 mask will be placed.
- DNS will put face shields on all the COVID 19 isolation carts to replace the need to use goggles exclusively. Staff were educated regarding the face shields usage and disposal. A few clean goggles were left in the isolation carts in case of need.
- Wide base resident testing will be completed every 2-3 days and as symptoms are present until the facility goes two weeks without any positive tests.
- Wide base staff testing will happen before staff members start their shift and as symptoms present until the facility goes two weeks without any positive test.
- The SSD called the first emergency contact for each resident and informed them of the current COVID outbreak.
- All new residents will be informed of the current COVID outbreak before admission to the facility.
- A sign was placed on all entrance doors to inform visitors about the COVID 19 outbreak and was placed next to the sign in sheet in the lobby.
- Facility acquired hand sanitizer to fill all dispensers and extra to make sure it is accessible to staff for proper hand hygiene.
- The DNS and designees will conduct spot checks of proper hand hygiene, donning and doffing PPE, signage and equipment cleansing. Any discrepancies will be brought to the QAPI team for further review.
- The DNS or designee will review the 24-hour report and bowel care list for any symptoms of clostridium difficile, and to ensure policies had been followed correctly. Any discrepancies will be brought to the QAPI team for further review.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for four residents, leading to potential unmet care needs. Resident 4, diagnosed with multiple sclerosis, had a care plan that required urinary catheter flushes three times a week. However, new physician orders indicated the need for flushes one to two times daily, which was not updated in the care plan. Resident 15, with heart disease, was at risk for falls and required non-slip material on walker handles. Despite the resident not using the non-slip material due to it coming off, the care plan was not updated to reflect this change. Resident 18, with atrial fibrillation, was prescribed apixaban, an anticoagulant, but the care plan did not include this medication. Lastly, Resident 48, who was bedbound and at moderate risk for falls, had bilateral fall mats in place, but the care plan was not revised to include this intervention. These oversights were acknowledged by the LPN Resident Care Manager, indicating a lapse in updating care plans to reflect current care needs and interventions.
Failure to Follow-Up on Critical Care Needs
Penalty
Summary
The facility failed to follow up on several critical care aspects for multiple residents, leading to unmet care needs. For Resident 4, who was admitted with multiple sclerosis, the facility did not obtain a new urine sample after the initial sample was improperly handled, resulting in a failure to diagnose a potential urinary tract infection. Staff did not communicate with the physician to obtain orders for a recollection, leaving the resident's condition unaddressed. Resident 15, admitted with heart disease, experienced a fall that was not observed by staff. The required neurological assessments were incomplete on multiple occasions, with staff incorrectly noting that the resident refused or was asleep. The resident later confirmed that they did not refuse the assessments, which were crucial for monitoring potential head injuries after the fall. Resident 163, who had undergone cervical spine surgery, did not receive proper wound assessments for their neck incision during their stay. The dressing was not removed until discharge, and no assessments were documented. Additionally, Resident 42, with spinal stenosis, did not receive a CT scan as ordered due to a lack of follow-up on the MRI alternative. Lastly, Resident 165, under hospice care, reported inadequate pain management, with staff failing to secure necessary medication adjustments despite repeated notifications to hospice.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of training annually. This deficiency was identified for three out of five sampled staff members. Specifically, one staff member hired in July 2016, another hired in July 2022, and a third hired in September 2021 did not complete the mandated training hours in the past year. This was confirmed by Staff 2, the Director of Nursing Services (DNS), during an interview and record review.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident of the risks and benefits associated with the use of psychotropic medication. A resident, admitted in 2024 with diagnoses of anxiety disorder and depression, was prescribed Lexapro, an antidepressant, as per a physician's order dated 7/18/24. However, a review of the medical record showed no documentation of risk and benefit information for Lexapro being provided to the resident. This was confirmed by Staff 2 (DNS) on 8/5/24, indicating that the necessary information was not reviewed with the resident.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which is a requirement for ensuring safe medication practices. Resident 11, who was admitted in August 2014 with a diagnosis of COPD, was observed on July 31, 2024, with two inhaler medications on the bedside table. The resident explained that these medications were used to aid in breathing. However, there was no assessment found in the medical record to determine the resident's capability to self-administer these medications. Staff 26, an LPN, confirmed that Resident 11 had not been assessed for self-administration of medications, acknowledging that such an assessment should have been conducted prior to allowing the resident to self-administer their medications. This oversight placed the resident at risk for improper medication administration.
Failure to Provide Resident Handbook and Rules
Penalty
Summary
The facility failed to provide rules and regulations governing resident conduct and responsibilities, specifically regarding the use of compact refrigerators in resident rooms. This deficiency was identified for one resident who was admitted in June 2024 with diagnoses including stroke and anxiety. The facility's Resident Handbook from January 2024 indicated that compact refrigerators might be approved for patient use. However, the resident, who was cognitively intact as per a July 2024 MDS, reported confusion after being denied a request for a personal refrigerator, as they had not received a copy of the Resident Handbook upon admission. The Administrator in Training acknowledged that since March 2024, residents had not been provided with the Resident Handbook as expected.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document advance directives for two residents, which placed them at risk of not having their healthcare decisions honored. Resident 12, admitted with a hip fracture, was noted to have an advance directive during a 72-hour admission huddle, but it was not included in their electronic record. This was confirmed by the Social Services Director. Resident 18, with a diagnosis of congestive heart failure, expressed a desire to formulate an advance directive during a care conference. However, a subsequent review of their medical record showed no evidence of an advance directive, and the resident reiterated their wish to complete one. The Social Services Director confirmed the absence of an advance directive for Resident 18 as well.
Failure to Notify Family of Resident Changes
Penalty
Summary
The facility failed to notify family members of significant changes in the condition and circumstances of two residents. Resident 4, who was admitted with multiple sclerosis and a history of decreased kidney function, experienced a change in mentation, loose stools, and dark orange urine, prompting a transfer to the hospital for evaluation. Despite the severity of the situation, the resident's emergency contact, identified as Witness 6, was not informed of the hospitalization, as confirmed by both Witness 6 and the facility's administrator. Similarly, Resident 266, who was admitted with dementia and a history of UTIs, was moved to a different room without prior notification to the family. Witness 3, a family member, was unaware of the room change until arriving for a visit. The facility's admission coordinator admitted to not considering the impact of the room move on the resident with dementia and acknowledged the lack of communication with the family regarding the change.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident admitted in March 2024 with diagnoses including palliative care and schizophrenia. Observations made over several days revealed persistent cleanliness issues in the resident's room. On multiple occasions, fall mats were observed with dried debris, dirt, and personal items such as a blanket and towels. Additionally, washcloths with a dark brown substance were found in the resident's sink. Despite staff entering and exiting the room, these cleanliness issues were not addressed. A Regional Nurse Consultant acknowledged the unhomelike environment during an observation.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and hygiene for two residents, both of whom were receiving hospice services. Resident 48, who was totally dependent on staff for personal hygiene care and dressing, was observed with greasy, uncombed hair, long jagged fingernails with brown debris, food on their face and in their mouth, facial hair, and a shirt with dried dark brown debris. A caregiver visiting Resident 48 reported that the resident did not receive the necessary ADLs care from the staff, which included washing hair, trimming and cleaning nails, shaving, applying lotion to dry feet, and changing into a clean shirt daily. The LPN-Resident Care Manager acknowledged that Resident 48 should be cleaned up daily, including being shaved per their request, and that all ADLs should be completed by staff. Resident 164, who required constant or intermittent supervision with physical assistance for grooming tasks, was observed with long fingernails with brown debris underneath. The LPN-Resident Care Manager confirmed that Resident 164's nails were long and needed cleaning. The care plan for Resident 164 directed staff to assist with combing hair, brushing teeth, shaving, and washing and drying the face and hands, but these tasks were not adequately performed, leading to the observed deficiency.
Failure to Investigate Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to investigate a new facility-acquired pressure ulcer for one of the two sampled residents reviewed for pressure ulcers. The resident was admitted in February 2020 with a diagnosis of hemiplegia on the left nondominant side. On February 9, 2024, the resident developed a stage 3 pressure ulcer on the sacrococcygeal area, which was documented in a wound evaluation on July 29, 2024, measuring 0.76 cm by 0.5 cm. Despite the presence of this ulcer, the facility did not conduct an investigation into its development. On August 2, 2024, the resident was observed to have an open stage 3 wound on the right upper buttock near the sacrococcygeal area, with surrounding red moisture-associated damaged skin. This lack of investigation placed residents at risk for worsening pressure ulcers.
Inadequate Care Leads to Increased UTI Risk for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents, leading to an increased risk of urinary tract infections (UTIs). Resident 4, who was admitted with multiple sclerosis and had a urinary catheter, required regular catheter flushes to prevent UTIs. However, from July 1 to July 19, 2024, the staff missed five out of eight scheduled flushes due to a lack of sterile solution. Despite a nationwide recall of sterile water, the facility did not notify the physician to seek an alternative solution, and no documentation was provided to confirm that the flushes were completed as ordered. Resident 266, admitted with dementia and a history of UTIs, experienced repeat UTIs likely due to poor perineum hygiene. The resident's care plan indicated a need for supervision in personal hygiene, but staff were not adequately informed or trained on the resident's unique needs. A CNA stated she was not aware of any specific instructions for Resident 266, and the LPN-Resident Care Manager admitted to not reviewing hospital notes or updating the care plan with personalized details. This lack of communication and documentation contributed to the resident's ongoing UTI issues.
Improper Maintenance of Respiratory Equipment for Residents
Penalty
Summary
The facility failed to maintain respiratory equipment for three residents, leading to potential respiratory issues. Resident 11, diagnosed with COPD, had nebulizer equipment improperly stored among unsanitary items such as an emesis bag, urinal, and dirty clothing. There was no documentation in the resident's medical record regarding the care and services of the nebulizer. Staff confirmed the equipment was not cleaned or stored properly. Similarly, Resident 164, with pneumonia and hypoxia, had nebulizer equipment stored unsanitarily with a bag of incontinent briefs and bedding on top. Again, there was no documentation of care and services for the nebulizer, and staff confirmed the improper storage and lack of record-keeping. Resident 267, diagnosed with kidney failure and sleep apnea, had a CPAP machine with a mask exposed on the bedside table, with bowel movement wipes placed on top. Flecks were observed inside the tubing, indicating it was dirty. There were no care plan interventions or treatments documented for the CPAP machine. Staff confirmed the improper storage and lack of follow-up to obtain orders or care plans for the CPAP machine. These deficiencies in maintaining respiratory equipment placed residents at risk for respiratory issues.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to evaluate and provide person-centered interventions for a resident with PTSD and anxiety, placing the resident at risk for re-traumatization. The resident was admitted in May 2024, and the care plan for trauma included interventions that were not personalized to the resident's specific triggers. The resident reported having disturbing nightmares related to combat and expressed that staff were not aware of how to assist with their PTSD. Despite requesting counseling, there was no follow-up to the request. Staff interviews revealed that the resident experienced one to three disruptive nightmares weekly, but these were not documented, and thus, the issue was not addressed. The Social Services Director confirmed that no PTSD assessment was completed upon the resident's admission, leaving details about the resident's PTSD unknown. Additionally, there was no formal training for PTSD when a new PTSD form was introduced, and the Director of Nursing Services acknowledged the need for improved evaluation and documentation of the resident's condition.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three of the five sampled Certified Nursing Assistants (CNAs). Specifically, CNA #3 and CNA #7 had not received performance reviews since 2022, and CNA #4 did not have any performance review documented in her record despite being hired on July 18, 2022. This deficiency was confirmed by Staff 2, the Director of Nursing Services (DNS), on August 1, 2024, at 8:30 AM.
Failure to Monitor Anticoagulant Medication
Penalty
Summary
The facility failed to monitor a resident's anticoagulant medication regimen, specifically apixaban, for adverse side effects. The resident, who was admitted in May 2016 with a diagnosis of atrial fibrillation, had a physician's order for apixaban dated July 11, 2022. However, a review of the resident's care plan on July 31, 2024, showed no evidence of a care plan for anticoagulant medication. Furthermore, a review of the medical record on August 2, 2024, revealed no monitoring for adverse side effects such as bleeding and bruising. Staff 23, an LPN Resident Care Manager, confirmed that the resident was not monitored for these potential side effects.
Failure to Implement GDR and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and adequately monitor psychotropic medications for two residents, placing them at risk for adverse medication reactions. Resident 12, admitted with anxiety disorder and depression, was administered multiple psychotropic medications, including Lexapro, Trazodone, Xanax, and Buspirone. Despite having known triggers that exacerbated anxiety, such as unexpected therapy visits and loneliness, these were not documented, and staff were unaware of them. The resident was not appropriately monitored for the effects of the medications, as acknowledged by the staff. Resident 15, admitted with heart disease, had their Wellbutrin dosage increased from 300 mg to 450 mg daily without documented justification or a recent GDR attempt. Progress notes indicated no exhibited behaviors or mood changes, and the last GDR was recorded in December 2022. Despite a psychotropic medication review in June 2024, no rationale was provided for the dosage increase or the absence of a GDR in December 2023, as confirmed by the LPN Resident Care Manager.
Unlocked Treatment Cart on Shasta Unit
Penalty
Summary
The facility failed to ensure that a treatment cart was locked on the Shasta Unit, which placed residents at risk for injury. During an observation on July 30, 2024, between 2:23 PM and 2:43 PM, the treatment cart was found to be unlocked in an alcove, with one wall blocking the view from the nurse's station. Nursing and therapy staff passed by the cart multiple times without securing it. At 2:43 PM, a Licensed Practical Nurse (LPN) who had just started her shift acknowledged that she was unaware the cart was unlocked and confirmed that it should have been locked.
Failure to Provide Therapeutic Diets
Penalty
Summary
The facility failed to prepare and serve therapeutic diets for residents requiring dietary restrictions, specifically for a resident with kidney failure and a hip fracture who was admitted in July 2024. The resident was prescribed a diet limited in salt, potassium, and phosphate, but on July 31, 2024, the resident was served sausage, which is high in salt and phosphates, instead of the prescribed alternative of roasted pork. The resident consumed the sausage, trusting the facility to provide the correct diet, which was crucial due to their dialysis treatments. The deficiency was further compounded by the lack of training for the cook, Staff 13, who was unaware of the need to provide alternative options for restricted diets and did not prepare the necessary pork roast. Additionally, the Dietary Manager, Staff 21, acknowledged that since the implementation of a new menu system in April 2024, no alternative menu items were purchased to accommodate therapeutic diets. This oversight led to the failure to follow the therapeutic diet requirements, as observed during the lunch service on July 31, 2024, where no pork roast was available, and sausage was served instead.
Failure to Provide Meals According to Resident Preferences
Penalty
Summary
The facility failed to provide meals according to residents' preferences, as evidenced by multiple instances where residents did not receive the food they ordered. Resident 1, who has anemia and acute kidney failure, reported frequently not receiving the meals she ordered, which is critical due to her self-limiting special diet. On one occasion, her lunch tray was missing potatoes, which she had selected. The Dietary Manager acknowledged awareness of these issues, indicating that such errors should not occur. Resident 214, with a history of stroke and anxiety, expressed dissatisfaction with receiving disliked foods such as beets, peas, and carrots, despite these preferences being documented in her care plan. The Dietary Manager confirmed ongoing issues with the new menu system and tray ticket accuracy, which began in April 2024. Additionally, a meal tray for another resident included an unrequested item, and there was a shortage of sausage, leading to a resident not receiving it despite their request.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which is a legal document stating that disputes will be resolved with a neutral party rather than in court. This deficiency was identified in three residents who were cognitively intact at the time of signing the agreement. Resident 9, admitted with Parkinson's disease, signed the arbitration agreement but later stated they did not recall anything about it. Staff 9, responsible for admissions, confirmed that she reviewed the arbitration agreement with residents or their representatives but did not follow up to ensure understanding. Witness 2, a family member of Resident 9, also did not understand the arbitration agreement and was only involved in discussions about financial eligibility. Similarly, Resident 53, admitted with heart disease, signed the arbitration agreement but later expressed no knowledge of what it entailed. Staff 9 again stated that she reviewed the agreement with the resident but did not ensure comprehension post-signing. Resident 165, also with Parkinson's disease, did not recall signing the arbitration agreement and misunderstood its purpose. Staff 9's consistent approach of not verifying residents' understanding after signing the agreement contributed to the deficiency, leaving residents uninformed of their legal rights.
Inappropriate Antibiotic Use for a Resident
Penalty
Summary
The facility failed to ensure that antibiotics were appropriately indicated for a resident diagnosed with multiple sclerosis, who was admitted in January 2024. The resident was administered antibiotics for a possible urinary tract infection (UTI) from late March to early April 2024. However, lab results from March 31, 2024, indicated that a urine culture was not required, suggesting no UTI was present. Despite this, the antibiotics were continued without documented rationale in the resident's clinical record. On August 2, 2024, a Licensed Practical Nurse (LPN) verified the absence of documentation justifying the continuation of antibiotics, which placed residents at risk for developing drug-resistant organisms.
Failure to Document and Administer Immunizations
Penalty
Summary
The facility failed to provide proper documentation and administration of immunizations, consents, and declinations for three residents, placing them at risk for infections. Resident 3, admitted with congestive heart failure, received COVID-19 vaccinations on three occasions but lacked signed consents for these vaccinations. Additionally, there was no evidence that COVID-19 booster vaccinations were offered, administered, or declined after the last recorded vaccination. Staff 1, the Administrator in Training, was unable to locate the necessary consents or evidence of booster offerings in the facility's records. Resident 20, who has chronic obstructive pulmonary disease, had no evidence in their medical record of being offered a pneumonia vaccination. Similarly, Resident 22, also with chronic obstructive pulmonary disease, received a COVID-19 booster but lacked a consent form for this administration. Staff 1 confirmed that the records for vaccination offerings, consents, and declinations were kept in a binder but was unable to locate the necessary documentation for these residents, indicating a lapse in the facility's record-keeping and vaccination protocol.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to unmet needs. Resident 20, who was admitted with hemiplegia on the left nondominant side, was observed multiple times with the call light hanging off the side of the bed, out of reach. Despite the resident softly calling for help, staff members walked past without assisting. It was only after a surveyor's intervention that a CNA confirmed the call light was not within reach and adjusted it accordingly. The LPN Resident Care Manager later confirmed that call lights are required to be within reach at all times. Resident 48, admitted with diagnoses including paranoid schizophrenia and chronic bed confinement, was also found with the call light inaccessible. Observations over several days revealed the call light was placed in a dresser drawer, out of the resident's reach. Staff members verified the call light's inaccessibility, despite the care plan indicating it should be within reach due to the resident's moderate fall risk and impaired mobility. The LPN Resident Care Manager acknowledged that the call light should have been accessible at all times.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by an incident involving a resident who felt their privacy was violated. The resident, who was cognitively intact and had a diagnosis of depression, reported a HIPAA violation by a staff member. During a bus trip, the staff member engaged the resident in a conversation about their preferred name and financial situation, including a statement about the resident's house being in foreclosure. This conversation was overheard by another resident, causing the resident in question to feel upset and violated. The resident expressed their distress to another staff member, who confirmed hearing the conversation and noted the resident's upset state. The staff member involved in the incident claimed to be trying to connect with the resident and denied any issues during a subsequent visit. However, an investigation confirmed the violation of the resident's HIPAA rights, leading to increased anxiety and distress for the resident. The incident was reported to the facility's administration, but no further information was provided regarding any additional actions taken.
Privacy Breaches for Two Residents
Penalty
Summary
The facility failed to maintain resident privacy for two residents, leading to potential psychosocial harm. Resident 263, who was cognitively impaired and discharged to a memory care facility, had her discharge location disclosed to unwanted family members by a former Social Service Director, despite only two family members being authorized to access her medical information. This breach of confidentiality was acknowledged by the facility's Administrator in Training. Resident 265, who was cognitively intact and admitted with depression, experienced a violation of privacy when a former Social Service Director discussed personal and financial matters inappropriately during a bus ride. The staff member admitted to asking probing questions about the resident's preferred name and finances, which upset the resident. The incident was witnessed by another staff member, who confirmed the resident's distress and assisted in filing a grievance. An investigation concluded that the resident's HIPAA rights were violated, causing increased anxiety and distress.
Neglect Resulting in Resident Burn from Hot Beverage
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in an injury. The incident involved a resident who was admitted with diagnoses including leg surgery and chronic pain. The resident, who was cognitively intact, requested tea from a staff member. The staff member, a former CNA, served the tea in a hydration mug with a straw without checking the temperature. The resident took a drink and suffered burns to the tongue and roof of the mouth due to the extremely hot temperature of the tea. The resident experienced significant pain, with skin peeling from the roof of the mouth, and the discomfort lasted for approximately two days. The facility's investigation confirmed that neglect occurred as the resident was injured by the hot tea. Interviews with staff revealed that training had been provided on serving beverages at safe temperatures, but the staff member involved failed to adhere to this protocol. The LPN-Resident Care Manager acknowledged the tea was hot enough to cause burns and confirmed that staff had been trained to ensure beverages were not too hot before serving them to residents.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the appropriate State Agency within the required two-hour timeframe. This deficiency involved a resident who was admitted to the facility with diagnoses including leg surgery and chronic pain. The resident, who was cognitively intact, requested tea from a staff member, which was served in a hydration mug with a straw. Upon drinking, the resident suffered burns to the tongue and roof of the mouth due to the hot temperature of the tea. The incident occurred in the evening, and the facility's administrator was notified the following morning. However, the facility did not report the incident to the State Agency until later that day, exceeding the two-hour reporting requirement. The facility's investigation concluded that neglect was substantiated as the resident was injured from the hot tea.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents, leading to unmet care needs. Resident 2, admitted with diabetes and dementia, did not have an initial care plan addressing diabetic goals and interventions, despite having multiple orders for diabetic care since admission. The resident received insulin regularly, but the lack of a diabetic care plan was acknowledged by the LPN-Resident Care Manager. Resident 266, with dementia and a history of UTIs, was identified as high risk for wandering, yet their care plan lacked goals or interventions for this risk. The resident was observed wandering in a wheelchair, attempting to leave the building. The LPN-Resident Care Manager confirmed the care plan was incomplete regarding elopement risk. Additionally, Resident 165, under hospice care, had no comprehensive care plan for hospice services or scheduled visits, as acknowledged by the DNS.
Failure to Secure Windows Poses Risk to Resident Safety
Penalty
Summary
The facility failed to ensure that windows on the first floor were properly secured, posing a risk of an unsecured environment for residents. Resident 163, who was admitted in May 2024 following spinal surgery, was placed in rooms where the windows had broken locking devices. Despite the use of locking devices, the windows could still be opened. This issue was confirmed by a complainant and later verified by a maintenance staff member, who admitted to being unaware of the problem. The deficiency was identified through observation, interview, and record review, highlighting a lapse in maintaining a safe environment for residents.
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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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