Avamere Rehabilitation Of Lebanon
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Oregon.
- Location
- 350 S. 8th, Lebanon, Oregon 97355
- CMS Provider Number
- 385168
- Inspections on file
- 25
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Lebanon during CMS and state inspections, most recent first.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
A resident admitted with diabetes and a documented non-pressure chronic ulcer on the left foot had an ulcer and scabs on multiple toes and the top of the foot noted on admission assessments, and an MDS later confirmed a non-pressure chronic ulcer. However, no physician orders or wound treatments for the left foot ulcer were present in the clinical record for an extended period after admission, until nursing staff eventually messaged the physician and initiated treatment. An agency LPN could not recall confirming wound care orders at admission and stated that usual practice would be to contact the physician if orders were missing, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds.
The facility did not involve staff or residents in determining staffing needs during its assessment, resulting in identified insufficiencies in staffing, training, and personnel. Interviews with a CNA, an LPN, and members of the Resident Council confirmed that input was not solicited and concerns about staffing and training were not addressed. No documentation was available to show that feedback or staffing data were incorporated into the assessment.
Surveyors found that staff failed to follow infection control protocols during a COVID-19 outbreak, including leaving used COVID-19 tests in open areas, not performing required hand hygiene, and not adhering to proper PPE use and signage. A resident with chronic respiratory illness was on special droplet precautions, but staff did not consistently follow posted guidelines or infection prevention policies.
The facility did not review resident rights during Resident Council meetings, as confirmed by both the Activity Director and Resident Council members. The Administrator acknowledged that resident rights were expected to be reviewed at these meetings, but this was not done.
The facility did not provide required written bed-hold notifications to residents or their representatives and failed to notify the LTC Ombudsman during transfers to hospitals and discharges home. This deficiency was confirmed for four residents with conditions such as heart failure, kidney disease, stroke, and alcohol abuse, with staff interviews and record reviews showing that these notifications were not completed as required.
Surveyors observed uncovered exterior refuse containers at multiple exits, each containing food debris and trash. Staff confirmed the lack of available lids, and facility leadership acknowledged the issue with uncovered refuse containers at several exterior doors.
A resident with chronic kidney disease and several recent hospitalizations did not receive a timely comprehensive assessment, as required. The annual MDS assessment was overdue, and there was no documentation of a significant change or admissions assessment after the resident's hospital returns. Facility staff acknowledged the delay and incomplete assessment.
A resident with a persistent vegetative state and traumatic brain injury did not receive timely referrals for PT, OT, SLP, or a neurologist as requested by family and indicated in the care plan. Staff were unclear about the referral process, and the resident's communication needs were not adequately assessed or addressed, resulting in delayed access to appropriate communication services.
A resident admitted with a leg fracture did not receive wound care as ordered by the orthopedic physician because the order was not entered into the TAR. The dressing was not removed or changed as directed, and staff did not assess the incision despite the resident's reports of pain. The omission led to the resident developing an incision infection, which was confirmed by staff interviews and record review.
A resident with a history of inhalant dependence and dementia was allowed to access and use smoking materials outside of designated areas and scheduled times, contrary to their care plan. Staff did not consistently secure smoking items in a lock box or monitor the resident as required, and the resident was observed leaving smoking materials unattended at the nurse's station and smoking independently outside the designated area.
Annual performance reviews were not completed for two CNA staff, as required. Personnel records indicated that the last evaluations for these staff members were not conducted within the expected annual timeframe, and the administrator confirmed the expectation for timely evaluations.
A resident with anxiety and heart failure exhibited new physically aggressive behavior, including banging a walker against the wall, which was not timely reported or documented by staff. Despite ongoing behavioral issues and ineffective interventions, key staff were unaware of the incident, and behavioral health staffing was noted as insufficient.
Treatment carts containing medications and medical supplies, including insulin, syringes, and antibiotics, were found unlocked and unattended in two hallways. Staff and residents were observed passing by the unsecured carts, and staff confirmed that carts are expected to be locked when unattended.
A resident with chronic kidney disease did not receive appropriate follow-up for dental services, despite facility policy requiring social services to coordinate and document such care. Although a dental referral was made, there was no evidence of a follow-up appointment or further action, and the Social Services Director could not provide documentation of any subsequent steps taken.
A resident dependent on staff for bathing, with diagnoses including COPD and metabolic encephalopathy, did not consistently receive scheduled showers as required by their care plan. Documentation showed missed showers on several scheduled days, with no evidence that additional opportunities were offered or refusals recorded. Staff interviews confirmed that blank logs indicated care was not provided, and one missed shower was attributed to short staffing.
The facility did not provide enough CNAs to meet required staffing ratios on multiple occasions, leading to missed showers, delayed bedtimes, and incomplete oral care for residents with significant care needs. Staff and residents reported frequent shortages, lack of management assistance, and continued admissions despite inadequate staffing, resulting in unmet resident needs and dissatisfaction.
A resident with diabetes, who was cognitively intact, reported missing money from their wallet. Staff investigated and ruled out theft due to inconsistent statements, offering to secure the remaining funds. However, the resident was not informed in a timely manner about the resolution or reimbursement, and staff failed to communicate the outcome as required by the facility's grievance policy.
A resident, who was cognitively intact and had a history of stroke, reported their cell phone missing after leaving it on their bedside table. Staff confirmed the resident had the phone the previous evening, and a search did not recover it. The phone was later located several blocks from the facility, indicating it had been taken. The facility failed to prevent the wrongful use or theft of the resident's belongings.
A resident with moderate cognitive impairment and dementia was subjected to a shirt change by a CNA despite repeatedly refusing the care and requesting to be left alone. The resident became visibly upset and distressed during the incident, which was witnessed and reported by other staff, and later confirmed by facility leadership as a failure to honor resident rights.
The facility failed to provide physician-ordered diets for three residents, leading to health risks. A resident with severe dysphagia was given incorrect food texture, causing a severe coughing episode. Another resident choked on inadequately prepared food, requiring emergency care. A third resident was served inappropriate food, leading to coughing. Staff were aware of errors but did not correct them due to a busy kitchen.
The facility failed to maintain proper meal temperatures and flavors, affecting food palatability and safety. A resident with malnutrition and diabetes reported consistently cold and bland meals, confirmed by staff observations. Sample plates during a lunch service were found to have cold, underdone, and unappetizing food.
The facility did not follow established recipes for meal preparation, as observed in the kitchen. A cook, employed for three weeks, reported not receiving recipes during training and did not follow any for lunch preparation. The Certified Dietary Manager confirmed that a new menu system with recipes was introduced, and they should have been followed for all therapeutic diets, risking residents' meal satisfaction and nutrition.
The facility did not monitor chemical concentration levels in the low-temperature dishwasher, risking improper sanitation. Staff were not instructed to check these levels, and the monitoring form lacked a section for documenting them. The Dietary Services Manager relied on monthly inspections instead of daily checks.
The facility failed to provide adequate staffing, resulting in long wait times for resident assistance, particularly during night shifts. Residents reported waiting up to 45 minutes for toileting help, leading to incontinence issues. Staff confirmed frequent CNA shortages and burnout, impacting their ability to complete care tasks. The administration acknowledged the staffing challenges.
The facility did not maintain RN coverage for eight consecutive hours per day on 34 out of 126 days reviewed, risking unmet assessment needs for residents. This issue was identified through staff daily report reviews, and facility leadership acknowledged the deficiency, noting the termination of two RNs.
The facility failed to post accurate staffing information, with multiple instances of missing LPN and CNA hours on the Direct Care Staff Daily Report (DCSDR). Staff were instructed to fill in numbers without hours, expecting administration to complete the form later. This issue was acknowledged by the Administrator and other staff members.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, as shown by records for five staff members. One CNA had only 15 minutes of training in a year. Facility leaders admitted that training sign-up sheets were not collected, preventing proper tracking of training hours, which risked resident care due to insufficiently trained staff.
The facility failed to maintain a clean and homelike environment for several residents, with observations of flooring damage, unclean bathrooms, and hallway stains. Residents with various medical conditions were affected, and the Maintenance Lead confirmed the need for repairs.
A facility failed to address a pest infestation, leading to flies and maggots in resident areas. A resident with diabetes and a foot ulcer was found with maggots on their bed, traced to their wound dressing, and was hospitalized. Despite a work order for flies, the issue was not addressed promptly, and pest control arrived days later. The resident returned to find flies still present, and the room required multiple cleanings. An investigation revealed the facility was unaware of the initial work order, placing residents at risk.
A resident with PTSD and anxiety was harassed by another resident, who repeatedly intimidated them by staring and following them to their room. Despite complaints and staff observations, the facility failed to take effective action to protect the resident, resulting in increased anxiety and feelings of being unsafe.
A resident with PTSD and anxiety disorder reported feeling harassed by another resident, who frequently visited their hall and room, causing fear and anxiety. Despite staff observations and reports, management failed to investigate or protect the resident, instructing staff to redirect the harassing resident, which proved ineffective.
The facility failed to revise care plans for three residents, leading to unmet needs. A resident with a broken arm was at risk for contracture, but the care plan lacked documentation. Another resident with aphasia and stroke had a care plan for ADL deficits and nutritional issues but lacked details on eating assistance. A third resident with alcohol dependency and narcissistic personality disorder was not care planned for alcohol dependency or worsening behaviors with alcohol consumption. Staff confirmed these deficiencies.
The facility failed to provide timely assistance with ADLs for three residents, leading to unmet needs. A resident experienced a delay in toileting assistance, resulting in an incontinent episode. Another resident missed several showers due to time constraints, leading to body odor, while a third resident received fewer showers than scheduled due to staffing shortages. Staff acknowledged the issues and the need for improved training.
A resident with dementia and depression was not provided with timely replacement of broken hearing aids, despite a care plan indicating their necessity for addressing a mild hearing deficit. Observations showed the resident without hearing aids, and staff confirmed they had been broken for months. The Social Service Director was unaware of the issue, believing the resident chose not to wear them.
The facility failed to prevent accidents and respond to condition changes in a timely manner. A resident with a leg fracture experienced a fall and delayed care due to inadequate communication with the on-call physician. Another resident, requiring two staff for transfers, fell during a solo transfer attempt by a CNA, resulting in a hospital visit.
A resident with a nephrostomy tube experienced inadequate care due to unclear staff responsibilities, lack of training, and supply issues, leading to concerns about bag placement and incidents of leakage. The care plan lacked specific interventions, and there were no orders for nephrostomy care for a period of time.
The facility failed to obtain necessary oxygen orders for two residents with COPD, leading to unmet respiratory needs. One resident used oxygen almost daily without a formal order, while another had continuous oxygen use without documentation of prescribed LPM or tubing changes. Staff confirmed these practices, highlighting a lack of proper documentation and adherence to physician orders.
The facility failed to complete an annual performance review for a CNA hired in 2021, with the only review dated in 2022. This oversight was acknowledged by the facility's leadership during an interview, attributing the missed review to a staffing transition, potentially risking resident care due to lack of competent staff.
A facility failed to provide risk and benefit information related to antipsychotic medication to a resident's responsible party before administration. The resident, with moderate cognitive impairment, was prescribed Haloperidol for anxiety and agitation. The consent form was signed after the medication was already administered, contrary to facility protocol.
A care conference for a resident with dementia was not conducted as scheduled, and no rescheduling was communicated. A family member inquired about the conference, and staff confirmed the resident's absence and lack of concerns from the family. Staff acknowledged the need for the resident, family, and IDT to be present at such conferences.
A resident with diabetes and a foot ulcer was not consulted about changes to their shower schedule following a room move, which conflicted with their medical appointments. The LPN acknowledged that the schedule should have been discussed with the resident beforehand.
A resident with diabetes refused multiple CBG checks and orthostatic blood pressure assessments over several months. Despite physician orders for these checks, the facility did not notify the provider of the refusals, as confirmed by a regional nurse consultant.
The facility did not provide meaningful activities for two residents, one of whom desired exercise activities but was not engaged in any for 30 days, while the other had no activity care plan and did not participate in activities. The Activities Director acknowledged the lack of exercise programming and the absence of an activity preference sheet for the residents.
The facility failed to manage medication and bowel care for two residents. One resident did not receive the correct Lisinopril dosage due to a delay in updating the chart, while another resident experienced a delay in receiving bowel care, despite a protocol for administering milk of magnesia for constipation. Staff confirmed these lapses, highlighting unmet needs in care delivery.
The facility failed to implement pressure ulcer treatments and care plans for two residents, leading to deficiencies in care. One resident developed new skin irregularities and an unstageable pressure injury, with missing documentation of skin assessments. Another resident acquired a Stage 4 pressure ulcer due to a contracted arm, with no investigation conducted. These failures highlight inadequate pressure ulcer care and prevention.
A facility failed to provide appropriate dialysis care for a resident with end-stage kidney disease. The resident reported that staff did not check the dialysis access site for thrill and bruit after dialysis sessions. The care plan required monitoring for infection and bleeding and documenting weights, but the clinical record showed insufficient documentation. Staff acknowledged the lack of documentation regarding the dialysis access site and daily weights.
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication side effects. One resident with dementia was prescribed medications without proper physician documentation, and another resident with diabetes had unaddressed pharmacy recommendations for lab testing. Staff acknowledged communication breakdowns and lack of documentation.
A facility failed to monitor a resident's anticoagulant medication, Apixaban, for adverse side effects. The resident, admitted with a stroke and blood clot, had a physician order for Apixaban, but there was no documentation of monitoring in their electronic record. A staff member acknowledged this oversight.
The facility failed to monitor adverse side effects for residents on psychotropic medications, including a resident with dementia on haloperidol, another with narcissistic personality disorder on multiple psychotropics, and a third with depression on antidepressants. Staff acknowledged the lack of required daily monitoring documentation.
Failure to Provide and Accurately Document Scheduled Bathing for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received required assistance with activities of daily living (ADLs), specifically bathing, and inaccurate documentation that bathing had been provided. The resident, admitted in 10/2025 with dementia and stroke, had a 10/21/25 admission MDS indicating severe cognitive impairment and dependence on staff for showers. The facility’s 12/2025 CNA task report showed the resident was scheduled for bathing on day shift on Wednesdays and Sundays. On 12/24/25, the task report was blank for bathing, and on 12/28/25, the report documented that the resident received bathing and was dependent on staff for assistance. However, a 12/29/25 facility investigation determined the resident did not receive a bath on 12/28/25 and that it had been falsely documented that bathing occurred. A Facility Reported Incident form dated 12/31/25 further documented that on 12/28/25, a CNA (Staff 5) noted providing bathing to the resident but did not provide any type of bathing. Additional record review showed that the resident’s 3/2026 CNA task report contained no documentation that any type of bathing was provided on 3/11/26. Attempts to contact Staff 5 on 3/16/26 and 3/17/26 were unsuccessful. During interviews, another CNA (Staff 7) stated that on 12/28/25 she observed Staff 5 lay the resident down and, when she asked about bathing, Staff 5 said she would complete the resident’s bathing in the evening; Staff 7 stated she could not perform the resident’s bathing in the evening because she moved to a different hall on evening shift. Another CNA (Staff 21) stated that usually if bathing was not documented in the resident’s record, bathing did not occur. The Regional Nurse (Staff 31) stated that staff should provide scheduled bathing to residents.
Failure to Obtain Orders and Treat Non-Pressure Foot Ulcer After Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders and provide treatment for a non-pressure skin wound on a resident’s left foot following admission. The resident was admitted in 10/2025 with diagnoses including diabetes and a non-pressure chronic ulcer on the left foot, and hospital admission orders documented an ulcer of the left second toe with skin breakdown and toe pain. On the admission Nursing Database assessment the day after admission, nursing staff recorded scabs on the resident’s second and fourth toes and the top of the left foot, and an admission MDS completed the following week indicated a non-pressure chronic ulcer on the left foot. Despite these documented findings, there were no physician orders or wound treatments in the clinical record for the left foot ulcer from admission through mid-November. A nursing note later documented that staff sent a message to the physician about the left second toe scab and that treatment was initiated at that time. In interviews, an agency LPN who completed the admission assessment could not recall whether she confirmed physician orders for the wound and stated that normal practice would be to contact the physician if there were no orders, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds. This failure to obtain and implement physician-directed wound care for the resident’s documented non-pressure ulcer and toe scabs during the identified period constituted the cited deficiency.
Lack of Staff and Resident Involvement in Facility Assessment
Penalty
Summary
The facility failed to demonstrate active involvement of staff and residents in determining staffing needs during its facility-wide assessment. The assessment identified insufficiencies in staffing, training, services, and personnel. Interviews revealed that CNAs and Resident Care Managers were not asked to provide input regarding staffing needs based on resident acuity, and there was no formal process for staff to give feedback to management about staffing. Members of the Resident Council reported that concerns about staffing had been discussed in meetings without resolution, and noted that agency staff required additional training. Documentation was not available to show how staffing hours or feedback from residents and staff were incorporated into the facility assessment.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during a COVID-19 outbreak affecting two halls. Used COVID-19 rapid tests were observed left on a bedside table near a facility exit and on top of the North Nurses Station, accessible to staff and residents passing by. Staff interviews confirmed that testing was supposed to occur in locked medication rooms, with used tests to be discarded immediately by a nurse, but this protocol was not followed. The Infection Preventionist acknowledged that the tests should not have been left in open areas and that the night nurse had left them out for an extended period. Additionally, signage for droplet precautions was found to be incorrect, with staff unable to see all necessary instructions, and the Infection Preventionist confirmed the signage did not meet expectations. Further observations revealed lapses in personal protective equipment (PPE) use and hand hygiene. A CNA was seen entering and exiting a room on droplet precautions without wearing a required face shield and failed to remove her N95 respirator before leaving the room. Another CNA was observed disposing of a used respirator and donning a new one without performing hand hygiene. The Infection Preventionist and other facility leaders stated that staff were expected to follow posted PPE guidelines and perform hand hygiene before donning clean masks, but these practices were not consistently followed. One resident involved had chronic obstructive pulmonary disease and was on special droplet precautions for COVID-19 at the time of the observed deficiencies.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. A review of Resident Council meeting minutes from three separate dates showed that resident rights were not reviewed during any of the meetings. During interviews, the Activity Director confirmed that resident rights were not discussed at Resident Council meetings, and members of the Resident Council also stated that these rights were not reviewed. The Administrator acknowledged that the expectation was for resident rights to be reviewed with residents during these meetings, but this did not occur.
Failure to Provide Bed-Hold Notification and Ombudsman Notification During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written bed-hold notifications and did not notify the LTC Ombudsman during resident transfers to hospitals and discharges home. Specifically, for four residents with various diagnoses including heart failure, kidney disease, weakness, stroke, and alcohol abuse, there was no evidence in the clinical records that written notice of the facility's bed-hold policy was given to the residents or their representatives at the time of transfer or hospitalization. Additionally, there was no documentation that the LTC Ombudsman was notified of these transfers or discharges, as required by facility policy. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written bed-hold notifications were not provided and that the Ombudsman was not notified for the affected residents. The lack of documentation and staff acknowledgment of these omissions demonstrate that the facility did not follow its own policies regarding resident notification and communication with the Ombudsman during transfers and discharges.
Uncovered Exterior Refuse Containers Observed
Penalty
Summary
The facility failed to provide covered exterior refuse containers for three out of four observed locations. On multiple occasions, surveyors observed uncovered refuse containers outside various exits, each containing food debris and other trash. Staff, including the Maintenance Lead, confirmed that there were no lids available for these containers. Both the Administrator and the Regional Director of Quality Assurance acknowledged the presence of uncovered refuse containers at three exterior doors.
Failure to Complete Timely Comprehensive Assessment After Multiple Hospitalizations
Penalty
Summary
The facility failed to complete a comprehensive assessment for one resident who had a history of chronic kidney disease and multiple recent hospitalizations. Upon review, it was found that the resident's annual Minimum Data Set (MDS) assessment, which was due, remained incomplete beyond the required timeframe. Additionally, there was no evidence in the clinical record that a significant change assessment or an admissions assessment had been completed following the resident's multiple hospitalizations and subsequent return to the facility. Both the Regional Reimbursement Analyst and the Administrator acknowledged that the comprehensive assessment was not completed in a timely manner, despite the expectation for timely and accurate MDS assessments for each resident.
Failure to Coordinate Communication Services for Non-Verbal Resident
Penalty
Summary
The facility failed to coordinate appropriate services to address the communication needs of a resident with a persistent vegetative state and traumatic brain injury. Upon admission, the resident's ability to understand others was not assessed, and although a physician order was made for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) at the family's request, there was no evidence that these referrals were promptly initiated. During a care conference, the family specifically requested referrals for OT, PT, SLP, and a neurologist, but staff were unclear about whether the SLP referral had been made. The resident's care plan was updated to reflect non-verbal communication needs, but staff interviews revealed uncertainty about how SLP could assist and a lack of timely follow-through on the requested services. Observations and interviews indicated that the resident attempted to communicate through non-verbal means such as eye movements, grunting, and swatting at staff. Staff members, including a CNA and the Activities Director, described the resident's responses to stimuli and attempts to make needs known, but there was no evidence of assessment for improved communication technology as requested by the family. The Regional Director of Quality Assurance confirmed that referrals for communication services were expected to be initiated as soon as requested, but acknowledged that there was a delay in providing these services for the resident.
Failure to Follow Physician Wound Care Orders Resulting in Infection
Penalty
Summary
The facility failed to follow physician orders for wound care for one resident who was admitted with a leg fracture. The orthopedic physician had ordered that the resident's dressing be removed one week after admission, the incision cleansed with warm water and soap, dried, covered with a nonadhesive pad or gauze, and the dressing changed every one to two days until a follow-up appointment. Staff were also instructed to monitor for signs of infection and contact Trauma/Orthopedics if any were observed. However, the physician's wound care order was not entered into the Treatment Administration Record (TAR), and there was no evidence that the wound care was completed as ordered. As a result, the resident's incision became red, swollen, and warm to the touch, with the resident reporting burning and tenderness. The resident stated that the dressing was not removed for nearly two weeks after admission and that staff did not check the incision until it became infected and painful, despite multiple reports of pain. Staff interviews confirmed that the physician's order was not placed on the TAR, dressing changes were not initiated, and the resident developed an incision infection. The process for entering and verifying new orders was reviewed, and it was acknowledged by multiple staff members that the order was missed.
Failure to Implement Smoking Safety Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to smoking safety for a resident with a history of inhalant dependence and inhalant-induced dementia, who was assessed as cognitively intact. The resident's care plan required smoking only in designated areas, adherence to a smoking schedule, and storage of tobacco and fire materials in a lock box at the nurse's station. However, observations showed the resident repeatedly accessed smoking materials from the nurse's station counter, exited through the North exit door, and smoked or vaped outside of the designated smoking area, contrary to the care plan. Staff interviews confirmed that the resident was allowed to smoke independently, outside of scheduled times and designated areas, and that smoking materials were not consistently secured in the lock box as required. Additionally, staff were unclear about the frequency of required checks for burns on the resident, and the resident was observed leaving smoking materials unattended on the nurse's station counter. The Director of Nursing Services acknowledged that the only designated smoking area was the courtyard and that staff were expected to secure smoking materials immediately, but this was not consistently done. These actions and inactions resulted in the facility failing to ensure a safe environment free from accident hazards related to smoking, as outlined in the resident's care plan.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for two of five sampled CNA staff. Personnel records showed that one CNA, hired in May 2020, had their last performance review in June 2024, and another CNA, hired in August 2018, had their last performance review in August 2024. The administrator confirmed that annual staff evaluations were expected to be completed in a timely manner.
Failure to Timely Address and Document New Behavioral Changes
Penalty
Summary
The facility failed to timely address a newly identified behavior in a resident with a history of anxiety and heart failure. The resident, who was cognitively intact and had documented episodes of depression, exhibited inappropriate behaviors such as refusal of care, confabulation, and verbal aggression on multiple days, as recorded in the behavior monitoring record. Despite these behaviors, interventions were largely ineffective, and there was no documentation of additional behaviors in the progress notes for over a month. Staff interviews revealed that the resident had recently displayed physical aggression by banging a walker against the wall, but this incident was not reported or documented by staff who witnessed it, as they assumed others were aware. Further interviews indicated that key staff, including the Social Services Director and the Director of Nursing Services, were unaware of the resident's physical aggression and expected such incidents to be documented to facilitate timely intervention. The Social Services Director acknowledged the need for a new behavioral assessment and consideration of additional behavioral services due to the change in the resident's behavior. The facility assessment also indicated insufficient behavioral health staffing, which may have contributed to the lack of timely response and documentation regarding the resident's behavioral changes.
Unsecured Treatment Carts with Medications and Supplies
Penalty
Summary
Surveyors observed that treatment carts containing medications and medical supplies, including insulin, needles, glucometers, IV supplies, syringes, anticoagulant, and antibiotic medications, were left unlocked and unattended in two separate hallways. On one occasion, a staff member noticed the unlocked cart and secured it, although she was not responsible for it. The charge nurse responsible for the cart stated she typically locked it but was unsure why it was left unlocked in this instance. In both cases, staff confirmed that the expectation was for treatment carts to be locked at all times when unattended. These observations were made during random checks, and in both instances, staff and residents were seen walking by the unsecured carts. The unlocked carts contained medications and supplies that should have been secured according to facility policy and professional standards. No specific residents were identified as being directly involved or affected at the time of the observations.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to follow up on dental services for one resident who was admitted with chronic kidney disease. According to the facility's policies, social services are responsible for assisting with dental appointments, transportation, and documenting all dental services in the resident's medical record. The resident's care plan required staff to coordinate dental care and transportation as needed. A review of the clinical record showed no evidence of dental services being referred or provided for the resident over a three-month period. Documentation indicated that a dental referral was made when the provider was at the facility, but there was no follow-up or documentation of a scheduled dental appointment, and the Social Services Director was unable to account for any further action taken.
Failure to Provide Scheduled Bathing and Shower Care
Penalty
Summary
A resident with chronic obstructive pulmonary disease and metabolic encephalopathy, who was dependent on staff for bathing and required two-person assistance, did not consistently receive scheduled bathing or shower care. The resident's care plan and admission assessments indicated the need for staff assistance with bathing. Bath/Shower task logs showed that showers were only documented as provided on three occasions, while scheduled shower days on three other dates were left blank with no documentation of care provided or refusals. Progress notes did not indicate that the resident was offered additional opportunities for bathing when a shower was missed or refused. Staff interviews revealed that sometimes tasks were not documented due to staff being too busy, and a resident care manager confirmed that blank logs indicated the task was not completed, with at least one missed shower attributed to short staffing.
Failure to Provide Adequate Staffing Resulting in Missed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents on multiple occasions, as evidenced by direct care staff daily reports, resident and staff interviews, and documentation reviews. On several dates, the number of Certified Nursing Assistants (CNAs) scheduled for both day and evening shifts was below the minimum required by Oregon state staffing ratios for the facility's census. This resulted in residents not receiving scheduled showers, delays in being put to bed, and missed oral care. Staff and residents consistently reported that management did not assist on the floor during shortages, and CNAs often skipped breaks or stayed late to complete tasks. Specific residents with diagnoses such as dementia, stroke, and cancer, who required assistance with activities of daily living (ADLs) like bathing, did not receive scheduled showers on the days when staffing was insufficient. Documentation was either missing or inaccurately indicated that residents refused care when, in fact, staff did not have time to provide it. Multiple staff members, including CNAs, LPNs, and the social service director, confirmed that showers and other care tasks were missed due to inadequate staffing, and that efforts to obtain agency staff were unsuccessful. The administrator and other management staff acknowledged ongoing staffing issues, confirming that resident needs were not met on the identified dates due to being short-staffed. The facility continued to admit new residents despite not having enough CNAs to provide required care, and staff reported that shortages were a frequent and unresolved problem. Residents expressed dissatisfaction with missed care, and staff described having to prioritize basic needs over other required tasks when working short.
Failure to Timely Resolve Resident Grievance Regarding Missing Property
Penalty
Summary
The facility failed to respond in a timely manner to a resident's grievance regarding missing property. According to the facility's grievance policy, grievances are to be addressed within five days of receipt, and the concerned party is to be informed of the resolution. A cognitively intact resident with a diagnosis of diabetes reported missing money from their wallet, specifying the denominations and amount believed to be missing. Staff, with the resident's permission, inspected the wallet and confirmed the discrepancy in the amount present. During the investigation, staff determined that theft was ruled out due to inconsistent statements from the resident, and the resident was offered the option to secure their remaining money. Despite this, the resident was not informed in a timely manner about whether the missing money would be reimbursed. Staff communication regarding the resolution was lacking, as one staff member was unsure about reimbursement and another did not communicate findings to the resident, assuming reimbursement would occur. The administrator acknowledged that the grievance policy was not followed, as the resident was not notified of the resolution within the required timeframe.
Failure to Protect Resident's Personal Property from Theft
Penalty
Summary
A resident with a history of stroke and documented as cognitively intact reported that their cell phone went missing after being placed on their bedside table following a call to their spouse. The resident stated that no one entered the room except staff and, occasionally, their roommate's visitors. Staff interviews confirmed that the resident had possession of the phone the evening before it was reported missing, and the phone was not found during a facility-wide search. The resident's spouse was able to use a phone locator to determine that the phone was located several blocks away from the facility the following day. The incident was reported to the police, and the resident's spouse subsequently requested reimbursement for the lost phone and the purchase of a new one. The report documents that the facility failed to protect the resident from the wrongful use or theft of their personal belongings, specifically the cell phone, as required. This deficiency was identified through interviews, record reviews, and the facility's own investigation into the missing property.
Resident's Right to Dignity and Self-Determination Not Upheld During Care
Penalty
Summary
A deficiency occurred when a staff member failed to honor a resident's right to dignity and self-determination. The resident, who was moderately cognitively impaired and diagnosed with dementia, was admitted to the facility in July 2024. On the date of the incident, a CNA attempted to change the resident's soiled shirt despite the resident's explicit refusal and requests to be left alone. The CNA proceeded to remove the shirt, which led to the resident becoming upset, fighting, and using strong language. The CNA later reported the resident's distress to an LPN, who confirmed the resident was angry about being made to change the shirt. Other staff members recalled the incident, with one CNA remembering the resident crying and reporting the situation to a nurse, and another LPN noting the resident appeared in distress and was forced to do something against their wishes. The resident did not use the word "abuse" but repeated the details of the incident, and two days later, no longer remembered it. The administrator and director of nursing services confirmed the accuracy of the incident and acknowledged the failure to maintain resident rights.
Failure to Provide Physician-Ordered Diets
Penalty
Summary
The facility failed to provide physician-ordered diets as prescribed for three residents, leading to significant health risks. Resident 57, who had a history of pneumonitis due to inhalation of food and severe dysphagia, was given food that did not meet the required minced and moist texture. This resulted in a severe coughing episode, indicating a risk of choking or aspiration. Staff were aware of the diet texture error but did not correct it due to a busy kitchen environment. Resident 3, diagnosed with difficulty swallowing, experienced a choking incident after being served inadequately prepared food. Despite a care plan that required supervision during meals and an easy-to-chew diet, Resident 3 choked on a piece of pork, leading to an emergency department visit. Documentation revealed multiple instances where Resident 3 refused to eat in the dining room, and there was insufficient staff to supervise meals in the resident's room. Resident 39, who had a stroke and dysphagia, was observed coughing while eating a tortilla, which was not appropriate for their easy chew 7 diet texture. The Certified Dietary Manager confirmed that the resident should have received bread instead. These incidents highlight the facility's failure to adhere to prescribed diet textures, posing significant health risks to the residents involved.
Removal Plan
- Resident 57 was assessed for signs and symptoms of aspiration, her/his physician was notified, and the resident was placed on alert charting.
- Staff 4 was suspended and slated for 1:1 inservice training related to food textures, ensuring food textures served matched the meal ticket, and the process for what to do if there was a discrepancy.
- Kitchen staff currently working were trained regarding proper diet textures. Other kitchen staff were slated to be educated until 100% were inserviced. Inserving was scheduled to be provided by a Certified Dietary Manager independent of the facility.
- Nursing staff were slated to be inserviced regarding appropriate food textures and ensuring residents received the correct texture.
- All residents with mechanically altered diets would have their meal tickets audited for correct texture prior to leaving the kitchen by the Certified Dietary Manager or designee, and a second check would occur by IDT team members in collaboration with CNAs prior to meals being served to residents.
- Audits would be conducted of each meal. All findings were to be reported to the QAPI committee. Audits were to be conducted by the Certified Dietary Manager or designee.
Deficiency in Meal Temperature and Flavor
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures and with proper flavor, affecting the palatability and safety of the food. On July 18, 2024, during a lunch service, sample plates were observed to contain cold and underdone au gratin potatoes, cold and firm broccoli, melted ice cream, and warm milk served at 64 degrees. The Certified Dietary Manager acknowledged these issues, confirming that the meal temperatures, flavors, and palatability were not appropriate. Additionally, a resident with diagnoses including malnutrition and diabetes reported consistent issues with the food quality. The resident stated that the food was bland, over-ripe, dry, tough, and always cold. Observations on July 18, 2024, during breakfast and lunch confirmed the resident's complaints, with meals appearing unappetizing and lacking flavor. A staff member, an RCM-LPN, also observed the resident's lunch and agreed that it did not appear appetizing or appealing.
Failure to Follow Menu Recipes
Penalty
Summary
The facility failed to adhere to established recipes to meet menu and therapeutic standards, as observed in the kitchen. On the specified date, the posted lunch menu included breaded pork cutlet, au gratin potatoes, and cauliflower, with an alternative menu of sloppy joes, cheddar mash potatoes, and broccoli. However, the cook, who had been employed for three weeks, reported that no recipes were provided during his training, and none were followed in preparing the lunch meal. The Certified Dietary Manager confirmed that a new menu system with recipes was introduced in June 2024, and recipes should have been printed and followed for all therapeutic diets. This failure placed residents at risk for lack of meal satisfaction and compromised nutrition.
Failure to Monitor Dishwasher Chemical Concentration
Penalty
Summary
The facility failed to ensure proper sanitation processes in the kitchen, specifically regarding the monitoring of chemical concentration levels in the low-temperature dishwasher. From July 1 to July 14, 2024, there was no documentation of chemical concentration levels, which are crucial for ensuring dishes are properly sanitized. On July 15, 2024, a Dietary Aide was observed using the dishwasher without monitoring the chemical concentration, as she had not been instructed to do so. The Dietary Services Manager acknowledged the oversight and admitted reliance on monthly inspections by the chemical supplier instead of daily monitoring. Additionally, the Certified Dietary Manager confirmed that the form used for monitoring the dishwasher was inadequate, as it did not include a section for documenting chemical sanitizer concentration, which should be logged daily.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple observations and interviews. Residents and staff reported long wait times for call lights to be answered, with some residents waiting up to 45 minutes for assistance with toileting and other needs. This issue was prevalent across different shifts, particularly during the night shift, and was corroborated by council meeting minutes and staff interviews. Residents expressed dissatisfaction with the delays, and staff acknowledged being overworked and unable to complete their tasks due to understaffing. Specific incidents highlighted the impact of insufficient staffing on resident care. For instance, a resident with a fractured pelvis and bladder incontinence waited 45 minutes for toileting assistance during dinner time, leading to episodes of incontinence. The resident's care plan required substantial assistance with transfers, but the staffing shortages hindered timely care. Staff confirmed the complaint and noted that call wait times often exceeded the facility's expectation of 15 to 20 minutes. Staff interviews revealed that the facility frequently experienced CNA shortages, with staff calling off work shortly before shifts. This led to incomplete care tasks, such as showers and incontinent care, resulting in skin issues for residents. Staff reported burnout and high turnover due to the ongoing understaffing, which further exacerbated the problem. The facility's administration acknowledged the staffing issues, confirming the challenges in meeting residents' needs effectively.
Failure to Maintain Consistent RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 34 out of 126 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Report sheets covering several periods from January to July 2024. Specific dates were noted where RN coverage was lacking, including multiple days in January, February, March, June, and July. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During an interview on July 19, 2024, the facility's administrator, director of nursing services (DNS), regional support lead, and regional nurse consultant acknowledged the issue, noting that they believed RN coverage was better than documented and reported that two RNs had their employment terminated.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as observed on multiple occasions. On several dates, the Direct Care Staff Daily Report (DCSDR) was posted without documenting staff hours for Licensed Practical Nurses (LPNs) or Certified Nursing Assistants (CNAs). Witness 1, a staff member, revealed that nurses were instructed to fill in staff numbers without hours, with the expectation that administration would complete the form the following day. This practice was confirmed by multiple staff members, including the Administrator and Regional Support Lead, who acknowledged ongoing issues with staff not adding up the hours on the DCSDR.
Inadequate CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records for five randomly selected staff members. Staff members hired between 2019 and 2022 had significantly less documented training than required, with one staff member having only 15 minutes of training over a year. During an interview, the facility's administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant acknowledged that staff were not obtaining sign-up sheets for trainings, which hindered the tracking of training hours. This deficiency placed residents at risk due to the lack of competent staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for several residents, as observed during a survey. Multiple residents, including those with reduced mobility, end-of-life care, heart disease, stroke, and anxiety disorder, were found to be living in rooms with significant flooring damage. Observations included dents with black marks on the floors, gray substance lines, and aged, dingy flooring. In some cases, the flooring was chipped, missing pieces, or had been patched with putty. Additionally, there were issues with the cleanliness of the bathrooms, with gray and black substances observed around toilets and on the floors. The survey also noted environmental deficiencies in the facility's hallways, where large dark stains and black coloration were observed on the carpet. Ceiling damage was also noted in one resident's room, with leakage damage and dark brown dried debris on the wall. These conditions were confirmed by the Maintenance Lead, who acknowledged the need for repairs. The report highlights the facility's failure to maintain a clean and homelike environment, impacting the quality of life for the residents involved.
Pest Infestation and Delayed Response in Resident Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies and maggots in resident areas. A work order was submitted on July 6, 2024, indicating an excessive amount of flies in the main area and resident rooms in the south part of the building. Despite this, the issue was not addressed until July 8, 2024, when the Maintenance Lead walked around the building but did not observe any issues. Pest control did not arrive until July 10, 2024. On July 13, 2024, a resident was found with maggots on their bed, which were traced back to their wound dressing, leading to their transport to the hospital. The resident had previously complained about flies landing on their food and foot, but no action was taken. The situation was further exacerbated when the resident returned from the hospital to find flies still present in their room. Staff were directed to deep clean the room, but the resident remained in the room during the process, necessitating a second cleaning. The facility administration was informed of the maggot issue early in the morning, but did not arrive until after noon. An investigation was conducted by the Director of Nursing Services and the Regional Nurse Consultant, who acknowledged the facility's lack of awareness regarding the initial work order related to flies. This oversight placed residents at risk for pest infestation, as flies were also observed in the dining room, where residents had to swat them away from their meals.
Failure to Protect Resident from Harassment
Penalty
Summary
The facility failed to protect a resident, who was cognitively intact and had a history of PTSD and anxiety, from harassment and intimidation by another resident. The issue began when the resident politely asked the other resident not to be disruptive in the dining room, which led to the other resident becoming angry and subsequently engaging in behavior that made the resident feel harassed and anxious. Despite the resident's complaints to management and staff observations of the intimidating behavior, the facility did not take effective action to prevent the harassment. Staff members reported that the resident felt scared, intimidated, and uncomfortable due to the other resident's behavior, which included staring and following the resident to their room. Although staff were instructed to redirect the harassing resident, this approach was ineffective and often resulted in the resident becoming angry. The facility's management was aware of the situation but failed to implement measures to protect the resident, leading to a deficiency in ensuring residents were free from abuse.
Failure to Investigate Allegations of Resident Harassment
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident with PTSD and anxiety disorder, who felt harassed and intimidated by another resident. The incident began when the resident asked the other resident not to be disruptive in the dining room, leading to ongoing harassment. Despite multiple observations and staff reports of the harassing behavior, management did not take adequate steps to protect the resident or investigate the allegations. Staff members reported that the harassing resident frequently visited the resident's hall and room, causing the resident to feel scared and anxious. Although staff were instructed to redirect the harassing resident, this approach was ineffective and further angered the resident. The facility's management was aware of the situation but failed to take appropriate action to ensure the resident's safety and well-being.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 10, admitted with a broken arm, was at risk for contracture to the left fingers. Despite instructions on the Treatment Administration Record (TAR) to soak and wash the hand and apply a hand brace, the care plan lacked documentation regarding the hand contracture. Staff confirmed that the hand contracture should have been included in the care plan. Resident 24, admitted with aphasia and stroke, had a care plan indicating deficits in ADL performance and nutritional issues but lacked documentation on whether supervision or assistance with eating was required. Staff acknowledged that supervision and cueing for eating assistance should have been specified. Resident 17, admitted with alcohol dependency and narcissistic personality disorder, had a behavior care plan but was not care planned for alcohol dependency or worsening behaviors with alcohol consumption. Staff confirmed that alcohol consumption worsened Resident 17's behaviors, yet the care plan did not address this issue. The lack of appropriate care plan revisions for these residents placed them at risk for unmet needs, as confirmed by facility staff.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to unmet needs. Resident 16, who was cognitively intact and required assistance with toileting due to bladder incontinence, experienced a delay in receiving help. Despite activating the call light, the resident waited 45 minutes for assistance, resulting in an incontinent episode. Staff confirmed the delay and acknowledged that the expected response time for call lights was 15 to 20 minutes. Resident 24, who had deficits in ADL performance due to stroke and dementia, was dependent on staff for bathing. Documentation revealed that the resident missed several showers, leading to body odor. Staff admitted that time constraints prevented completion of all tasks, and showers were sometimes falsely documented as refused. Similarly, Resident 40, who required assistance for personal hygiene, received fewer showers than scheduled due to staffing shortages. Observations noted poor hygiene, and staff acknowledged the need for improved training to ensure compliance with bathing schedules.
Failure to Timely Replace Hearing Aids for a Resident
Penalty
Summary
The facility failed to replace hearing aids in a timely manner for a resident with dementia and depression, leading to a deficiency in addressing sensory needs. The resident was admitted in 2022 and was assessed to have adequate hearing with the use of hearing aids. A care plan revised in June 2024 indicated the resident was to wear hearing aids in both ears to address a mild hearing deficit. However, observations in July 2024 revealed the resident was not wearing hearing aids, and staff confirmed the aids had been broken for three to four months. The resident was on a list for repair, but no action had been taken. Staff members, including a CNA and an LPN, acknowledged the absence of hearing aids since the resident moved to a new hall in April 2024. The Social Service Director was unaware of the issue, mistakenly believing the resident chose not to wear the aids.
Failure to Prevent Accidents and Timely Response to Condition Changes
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not respond to changes in condition in a timely manner. Resident 65, who was admitted with a leg fracture, experienced a fall resulting in a swollen, bruised, and painful right lower extremity. An x-ray confirmed a right ankle fracture, but there was a delay in notifying the on-call physician and sending the resident to the emergency room. Staff 42 acknowledged not calling the on-call physician and only sending a message through the hospital messaging system, which delayed the necessary care for Resident 65. Additionally, the facility did not adhere to the care plan for Resident 66, who required two staff members for mechanical lift transfers due to diagnoses including COPD, generalized muscle weakness, and a transient ischemic attack. An incident occurred when a CNA attempted to transfer Resident 66 alone, resulting in the resident falling out of the lift sling and hitting her head on the floor. The care plan was not followed, as the transfer was conducted by one staff member instead of two, leading to the resident being sent to the hospital. Staff 43 admitted to not following the care plan due to being rushed.
Inadequate Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a nephrostomy tube, which placed the resident at risk for urinary infections. The resident was admitted with chronic kidney disease and had a nephrostomy tube placed. There was a physician order to cover the nephrostomy tube site and change the bandage daily, but there were no orders for nephrostomy care from March to May. The care plan was revised in July to include monitoring for complications, but it lacked specific interventions related to the nephrostomy. The resident expressed concerns about the placement and staff knowledge regarding the nephrostomy bag, reporting incidents of the bag bursting or leaking due to improper handling. Staff interviews revealed confusion about responsibility for the nephrostomy bag care, unclear instructions on bag placement, and issues with supply availability. Staff acknowledged the need for a systematic method to maintain supplies, additional CNA training, and a detailed care plan for the nephrostomy bag care and placement.
Failure to Obtain Oxygen Orders for Residents with COPD
Penalty
Summary
The facility failed to obtain necessary orders for oxygen use for two residents with chronic obstructive pulmonary disease (COPD), leading to unmet respiratory needs. Resident 30, admitted in April 2022, had a care plan for oxygen use as needed but lacked a current order for oxygen use in their medical record. Staff confirmed that Resident 30 used oxygen almost daily when experiencing shortness of breath, yet no formal order was documented. Similarly, Resident 63, admitted in 2024, had a physician order for oxygen at three liters per minute (LPM) as needed. However, the medical record showed continuous oxygen use without documentation of adherence to the prescribed LPM or the frequency of oxygen tubing changes. Staff confirmed the continuous use of oxygen, acknowledging the absence of a formal order for such use and the lack of documentation regarding tubing changes.
Missed CNA Performance Review During Staffing Transition
Penalty
Summary
The facility failed to complete annual performance reviews for a Certified Nursing Assistant (CNA), identified as Staff 9, who was hired on March 23, 2021. The only performance review provided for this staff member was dated April 30, 2022. This oversight was identified during an interview conducted on July 19, 2024, with the facility's Administrator, Director of Nursing Services (DNS), Regional Support Lead, and Regional Nurse Consultant. They acknowledged that the missed review occurred during a staffing transition, which placed residents at risk due to the potential lack of competent staff.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents or their responsible parties prior to administration. This deficiency was identified for one of the five sampled residents, who was admitted with a diagnosis including dementia. The resident, who had a BIMS score indicating moderate cognitive impairment, was prescribed Haloperidol for anxiety and agitation. The medication was administered starting on 5/9/24, but the consent form for the use of psychotropic medication therapy was not signed until 5/16/24. This indicates that the responsible party was not informed about the risks and benefits of the medication before it was administered. During an interview, facility staff confirmed that medication consent forms were expected to be signed before administration, highlighting a lapse in protocol adherence.
Failure to Conduct Scheduled Care Conference
Penalty
Summary
The facility failed to conduct a care conference for a resident with dementia, admitted in November 2021, as scheduled. On July 18, 2024, a family member, Witness 6, reported that a care conference was scheduled for May 27, 2024, but it did not occur, and no rescheduling was communicated. Staff 15, an LPN Assistant RCM, confirmed the scheduled conference and noted that Witness 6 had no concerns when she inquired about it on the scheduled date, but also confirmed that the resident was not present. Similarly, Staff 33, the Social Service Coordinator, confirmed the absence of the resident and the lack of concerns from Witness 6. On July 19, 2024, Staff 32, an LPN RCM, and Staff 31, an SSD, both stated that care conferences should include the resident, family, and the interdisciplinary team (IDT), which comprises nursing, social services, therapy, dietary, and activities. Staff 31 acknowledged that the care conference did not occur and mentioned efforts to reschedule it.
Failure to Include Resident in Shower Schedule Decisions
Penalty
Summary
The facility failed to include a resident in decisions regarding their shower schedule, which is a violation of the resident's right to self-determination and choice. The resident, who was admitted in 2024 with diagnoses including diabetes and a foot ulcer, required assistance with transfers and dressing. A revised care plan indicated these needs. The resident's shower schedule was changed automatically following a room move, without prior discussion or consent from the resident. This change conflicted with the resident's weekly medical appointments, causing inconvenience. Staff acknowledged that the shower schedule should have been discussed with the resident before any changes were made.
Failure to Notify Provider of Resident's Refusals for Health Checks
Penalty
Summary
The facility failed to notify the provider of a resident's refusals for critical health checks, specifically capillary blood glucose (CBG) checks and orthostatic blood pressure measurements. The resident, admitted in September 2019 with a diagnosis of diabetes, had physician orders for weekly CBG checks and monthly orthostatic blood pressure assessments. However, the resident refused CBG checks on multiple occasions in May, June, and July 2024, and also refused orthostatic blood pressure checks in May and June 2024. Despite these refusals, there was no evidence in the medical record that the provider was informed of these refusals, as confirmed by a regional nurse consultant on July 19, 2024.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to assess and provide meaningful activities for two residents, leading to a lack of social interaction. Resident 36, who was cognitively intact and expressed a desire for group activities, particularly exercise, was not engaged in any activities for 30 days. Despite being aware of Resident 36's interest in exercise, the Activities Director acknowledged that current activities did not include exercise programming. Resident 42, diagnosed with an anxiety disorder, had no activity care plan, and did not participate in any activities for 30 days. The Activities Director admitted that an activity preference sheet was not completed for Resident 42.
Medication and Bowel Care Deficiencies
Penalty
Summary
The facility failed to implement proper medication management and bowel care for two residents, leading to unmet needs. Resident 17, who was admitted with a diagnosis of diabetes, had a physician's order to increase their Lisinopril dosage from 5 mg to 7.5 mg on 5/7/24. However, this change was not entered into the resident's chart until 6/15/24. During this period, the pharmacy sent the correct dosage, but staff continued to administer the incorrect 5 mg dose as per the outdated chart. Staff members, including an LPN and CMA, confirmed the discrepancy, and the DNS acknowledged the failure to update the chart promptly, leaving uncertainty about the duration the resident received the incorrect dosage. Resident 33, admitted with arthritis, experienced a lapse in bowel care. From 6/7/24 to 6/13/24, the resident did not have a bowel movement, and although the MAR indicated that milk of magnesia should be administered every 24 hours as needed for constipation, the resident only received the medication on 6/12/24, five days after the last recorded bowel movement. The facility's administrator, DNS, regional support lead, and regional nurse consultant confirmed that bowel care should have been provided sooner, indicating a failure to adhere to the prescribed bowel management protocol.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to implement appropriate pressure ulcer treatments and care plans for two residents, leading to deficiencies in care. Resident 3, admitted with a diagnosis of stroke, developed new skin irregularities with significant redness in the peri and sacral areas, as noted in a weekly skin audit. However, there was no documentation that the physician was informed of these changes. The Treatment Administration Record (TAR) indicated that bi-weekly skin checks were to be conducted, but there were inconsistencies in the documentation, with missing assessments for several dates. An external physician visit later identified an unstageable pressure injury on Resident 3's buttocks, and the physician requested an off-loading mattress and a facility skin assessment, which was not documented in the clinical records. Resident 1, admitted with an anoxic brain injury, developed an in-house acquired Stage 4 pressure ulcer on the left upper abdomen. Despite the severity of the ulcer, there was no investigation conducted to determine its cause. Staff interviews revealed that the ulcer was caused by the resident's contracted left arm pressing against the abdomen, but no further action was taken to investigate or address the issue. This lack of investigation and documentation highlights the facility's failure to provide adequate pressure ulcer care and prevention.
Failure to Provide Proper Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage kidney disease, who was admitted in 2024. The resident, who underwent dialysis three times a week, reported that upon returning from dialysis, staff did not check the access site for thrill and bruit, which are essential to ensure good blood flow in a dialysis fistula. The care plan dated 2/7/24 required staff to monitor the access site for infection and bleeding and to document weights. However, the resident's clinical record showed only six weights documented from 2/7/24 through 6/29/24, with no evidence of access site monitoring. Staff acknowledged the absence of documentation regarding the type of dialysis access site and the necessary care needs for the resident, as well as the lack of daily weight documentation.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication side effects. Resident 10, who was admitted with a diagnosis of dementia, was prescribed trazodone and promethazine for agitation, both limited to 14 days. However, the notes to the attending physician lacked the physician's signature, date, or clinical justification for extended use. The Medication Administration Record (MAR) indicated that trazodone was administered every 12 hours as needed for agitation, and promethazine every four hours as needed for agitation, nausea, and vomiting. A communication breakdown between the provider and the facility was acknowledged by the staff during an interview. Resident 17, admitted with a diagnosis of diabetes, had pharmacy recommendations for laboratory testing in May 2024. However, a review of the resident's medical record revealed that the last lab tests were completed in April 2023, and there was no documentation related to the May 2024 pharmacy recommendations. Staff confirmed that the resident often refused lab testing due to a fear of needles, and there was no documentation regarding the pharmacy recommendation for lab testing.
Failure to Monitor Anticoagulant Medication
Penalty
Summary
The facility failed to monitor the anticoagulant medication, Apixaban, for adverse side effects in one of the five sampled residents. This resident was admitted in 2023 with diagnoses including stroke and blood clot. A physician order dated 3/28/24 indicated that the resident was to receive Apixaban. However, there was no documentation in the resident's electronic record regarding the monitoring for adverse side effects of this medication. On 7/18/24, a staff member, identified as Staff 28 (RCM-LPN), acknowledged the absence of monitoring for adverse side effects in the resident's electronic record.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to consistently monitor residents on psychotropic medications, leading to the risk of residents receiving unnecessary medications. Resident 10, admitted with dementia, was administered haloperidol daily without daily documentation of monitoring for antipsychotic side effects. During an interview, facility staff acknowledged the expectation for daily monitoring, which was not met. Resident 17, with a diagnosis of narcissistic personality disorder, was prescribed four psychotropic medications, including olanzapine, diazepam, duloxetine, and trazodone. Despite a care plan in place since 2021 to monitor for adverse side effects, there was no evidence of such monitoring in the resident's medical record. Staff confirmed the lack of documentation. Similarly, Resident 27, diagnosed with depression, was prescribed Zoloft and Remeron, but there was no monitoring for adverse side effects documented in the electronic record, as confirmed by staff.
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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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