Cedar Crossings
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6003 Se 136th Avenue, Portland, Oregon 97236
- CMS Provider Number
- 385284
- Inspections on file
- 24
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cedar Crossings during CMS and state inspections, most recent first.
A resident with dementia, anxiety, sensory impairments, frequent falls, and documented high elopement risk had care plan interventions for frequent monitoring and staff awareness of wander risk, and was listed in the facility’s elopement records. Progress notes described ongoing exit-seeking behavior and a prior elopement in which the resident left through the front door with belongings and was later found in the community. Despite this, multiple staff members, including CNAs, a CMA, and an RN, reported they did not know the resident was an elopement risk or that elopement interventions were in place, while only an LPN recognized the resident as an exit seeker who dressed neatly and sat near the exit. Observations showed the resident fully dressed, making the bed, cleaning the room, and repeatedly stating an intention to go home, while leadership acknowledged staff were not following the care plan or aware of the elopement risk.
The facility failed to provide a safe and homelike environment, with tripping hazards in the dining room and damaged flooring and walls in resident areas. A resident with a history of stroke experienced discomfort due to cold room temperatures, which staff struggled to regulate. Other residents reported similar temperature issues, highlighting a broader problem within the facility.
The facility failed to enforce smoking policies and conduct timely assessments for three residents, leading to potential hazards. A resident with chronic heart failure kept smoking materials unsecured, contrary to policy. Another resident with kidney disease had delayed assessments and also kept materials unsecured. A third resident with schizoaffective disorder had no initial assessment or care plan, and staff were unclear about the policy. The facility acknowledged these issues, indicating a systemic problem in policy enforcement.
The facility failed to provide adequate nursing staff, resulting in prolonged call light response times for residents with conditions such as morbid obesity, diabetes, and cancer. Staff interviews confirmed that response times were longer during short-staffed periods, and the facility did not meet state minimum CNA and bariatric staffing ratios on several occasions.
The facility did not complete annual performance reviews for five CNAs, as confirmed by the DNS and Administrator. This oversight was identified during an interview and record review, where it was found that the personnel profiles lacked the necessary documentation, potentially compromising resident care.
The facility failed to properly store, label, and dispose of medications, as observed in three out of four medication carts. Expired and improperly labeled medications, including insulin and Naloxone, were found, and a medication cart was left unlocked and unattended. Additionally, Lorazepam tablets for a resident without an order and multiple opened medicated creams without open dates were discovered. Staff was uncertain about labeling requirements, and the DNS expected adherence to the facility's policy.
A resident with severe cognitive impairment and dysphagia was not provided with necessary dental services since admission, despite having broken and decayed teeth. Observations and family reports indicated poor oral hygiene, and staff confirmed the resident was not seen by a dentist. The facility failed to address the resident's dental needs, as confirmed by the DNS.
A resident with deep vein thrombosis, atrial fibrillation, and high blood pressure experienced leg discomfort due to swelling. Despite a provider's order for compression stockings, the resident did not receive them, and they were not observed on the resident. A progress note indicated an order for Tubigrip, but it was not implemented due to an oversight. The DNS expected orders to be processed and implemented.
A resident with sleep apnea was found to have a dusty BIPAP machine with improperly stored tubing and mask, and no distilled water available. Staff interviews revealed inconsistencies in cleaning responsibilities, and there was no physician's order for the machine. The RNCM acknowledged the lack of proper maintenance and oversight, placing the resident at risk for breathing complications.
A resident with end-stage renal disease did not receive prescribed medications before dialysis, as staff administered only a pain medication prior to departure. The resident's other morning medications were given after returning from dialysis, contrary to physician orders. Additionally, Pre/Post Dialysis Communication forms were often inaccurate or incomplete, with staff acknowledging inconsistencies and lack of proper documentation.
A facility failed to address a pharmacist's recommendation to increase a resident's Melatonin dosage due to insomnia. Despite the pharmacist's suggestion to increase the dosage from 1 mg to 3 mg, the clinical record showed no follow-up action. Staff interviews confirmed that the provider did not respond to the recommendation, leading to delays in addressing the resident's medication needs.
The facility failed to maintain proper waste containment and sanitation in the garbage storage area. Observations revealed uncovered dumpsters with overflowing garbage bags spilling onto the ground. The Dietary Manager acknowledged the issue, noting that garbage collection occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed the facility's policy to keep garbage contained and the area clear of debris, and staff were educated on maintaining closed dumpsters.
The facility failed to follow infection control practices for two residents, one with a PEG tube and another with a Foley catheter. Staff did not adhere to enhanced barrier precautions, such as wearing gowns, during hands-on care, despite the presence of instructions and the need for such precautions due to the residents' medical conditions.
The facility did not ensure that CNAs received the mandatory 12 hours of annual in-service training. A review of records for five staff members showed no completed training hours, which was confirmed by the DNS and Administrator.
The facility failed to provide written transfer notices with appeal rights to two residents and their representatives when they were transferred to the hospital. One resident, admitted with a stroke and swallowing difficulties, and another with gallbladder issues, were both transferred without receiving the required notifications. The DNS confirmed that these notifications were not being provided, despite expectations.
The facility failed to provide two residents with a written bed hold notification, including reserved payment details, when they were transferred to the hospital. One resident with a stroke and swallowing difficulties and another with gallbladder issues did not receive the required notice. The DNS confirmed the oversight.
A resident with chronic kidney disease and requiring dialysis requested bed rails for bed mobility upon admission. Despite being cognitively intact and needing moderate assistance, the resident had to use the headboard to reposition themselves and waited weeks for bed rails. A public complaint and grievance form highlighted the delay. An LPN recalled the request and claimed an assessment was done, but the DNS stated no assessment was completed, although a physician order was initiated. The administrator acknowledged the delay in providing the bed rails.
A facility failed to allow a resident to return after a therapeutic leave, exceeding the bed-hold policy. The resident, with diagnoses including heart failure and homelessness, was out of the facility and upon return, was informed of discharge against medical advice. Despite returning to her/his room, the resident was escorted out, and a complaint was filed alleging belongings were locked up. The administrator confirmed the resident was not permitted to return after being late from leave.
A resident with hypertension was discharged from a facility and transported to another state without a meal for the extended journey. The discharge instructions did not include a meal provision, and staff confirmed that no meal was sent with the resident. The facility administrator acknowledged this oversight.
A resident admitted with cataracts in both eyes did not receive timely optometry services as outlined in their care plan. Despite requests for an eye exam since admission, the facility failed to schedule an ophthalmology appointment until recently. A staff member acknowledged the delay in scheduling the necessary vision appointment.
A resident admitted with congestive heart failure and diabetes had dental care needs due to being edentulous. Despite requesting a dental exam and dentures, the facility failed to schedule any dental appointments from admission in 2022 until new orders in 2023. Observations confirmed the resident was missing most natural teeth, and staff acknowledged the delay in scheduling a dental appointment.
A resident with cognitive impairment and aphasia eloped from the facility due to inadequate re-evaluation of elopement risks and care plan interventions. Despite being identified as an elopement risk, the resident's exit-seeking behaviors were not consistently documented or communicated among staff, leading to an immediate jeopardy situation. The facility's Wandering and Elopement policy was not effectively implemented, resulting in the resident's continued missing status.
The facility did not develop or present a QAPI plan to the SSA and lacked documentation of an ongoing QAPI program. The administrator confirmed the absence of these essential components during the survey.
The facility did not conduct quarterly QAA meetings and failed to involve the Medical Director in quality assurance activities. This was confirmed by the Administrator, who acknowledged the lack of meetings and the Medical Director's absence, putting residents at risk of not receiving optimal care.
Failure to Ensure Staff Awareness of Resident Elopement Risk and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were aware of a resident’s elopement risk and corresponding care plan interventions. The resident was admitted with dementia with anxiety, bilateral hearing loss, cataracts, visual impairment, and a history of frequent falls. A care plan dated 5/21/25 identified the resident as at risk for elopement due to poor cognition, with interventions including frequent monitoring, visual checks, and ensuring staff awareness of the resident’s wander risk. Progress notes on 6/17/25 documented exit-seeking behavior, administration of an anxiety medication for anxiety and exit seeking, and an elopement later that evening when the resident left the facility through the front door with belongings, walked in the community, and was later found by a bystander. Subsequent assessments and documentation, including an elopement assessment on 12/3/25 and an annual MDS on 1/29/26, identified the resident as high risk for elopement with moderate to severe cognitive impairment and functional limitations in ADLs, reduced safety awareness, and impaired sequencing. The resident was also listed in the facility’s Elopement Book as a high elopement risk, and progress notes continued to describe exit-seeking behavior. Despite these documented risks and interventions, multiple staff interviews and observations showed that staff were not aware of the resident’s elopement risk or care plan interventions. On 4/2/26, several staff members, including a SSD assistant, CMA, and CNAs, either were unaware the resident had previously eloped or did not know the resident was an elopement risk or had elopement interventions in place. An RN stated there were no residents in her section who were an elopement risk, while an LPN identified the resident as an exit seeker who dressed nicely and sat by the door, noting visitors could mistake the resident for another visitor. Observations on 4/2/26 and 4/3/26 showed the resident fully dressed, sitting on the side of the bed, making the bed, cleaning the room, and repeatedly stating a desire to go home and intent to go home. The administrator and DNS later acknowledged that staff did not follow the resident’s care plan and were not aware of the resident’s elopement risk.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several deficiencies observed in the dining rooms, hallways, and resident rooms. In the Enhanced Care Unit (ECU) dining room, there were significant tripping hazards due to missing and damaged linoleum flooring. Staff confirmed that these issues had been present for some time and had been reported to maintenance, yet no warnings were in place to alert residents of the hazards. Additionally, various resident rooms and shared spaces exhibited damage such as scrapes on walls and black marks on floors, further detracting from a homelike environment. Resident 68, who was admitted with a diagnosis of cerebral infarction, experienced discomfort due to the inability to regulate the temperature in her/his room. The room was consistently cold, particularly from midnight to 8:00 AM, despite attempts by staff to adjust the thermostat. The Maintenance Director acknowledged the difficulty in maintaining a comfortable temperature and noted that unauthorized adjustments to the thermostat could exacerbate the issue. Other residents in nearby rooms also reported similar temperature concerns, indicating a broader issue with temperature regulation in the facility.
Failure to Enforce Smoking Policies and Timely Assessments
Penalty
Summary
The facility failed to ensure timely smoking assessments and safe storage of smoking materials for three residents, leading to potential accident hazards. Resident 22, admitted with chronic heart failure and diabetes, was assessed as safe to smoke independently. However, observations revealed that Resident 22 kept smoking materials in their pocket, contrary to the facility's policy requiring these materials to be locked up. Staff interviews confirmed that Resident 22 did not comply with the policy, and there was no evidence that the facility enforced the safe storage requirement. Resident 50, with end-stage kidney disease and diabetes, was also assessed as safe to smoke independently. However, the initial smoking assessment was missing, and the quarterly assessment was delayed. Observations showed that Resident 50 kept smoking materials with them, and staff interviews indicated a lack of clarity and enforcement regarding the storage policy. Despite being aware of the policy, staff acknowledged that Resident 50 did not comply with the requirement to lock up smoking materials. Resident 60, diagnosed with schizoaffective disorder and kidney disease, was found to have no initial smoking assessment or care plan related to smoking until months after admission. Observations and interviews revealed that Resident 60 kept smoking materials unsecured, and staff were uncertain about the current smoking policy. The facility's Director of Nursing Services acknowledged the delay in assessment and the absence of a care plan, highlighting a systemic issue in policy enforcement and resident compliance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for several residents. Resident 26, admitted with morbid obesity and diabetes, reported call light response times of up to 45 minutes, with logs showing multiple instances of delays exceeding 30 minutes. Similarly, Resident 22, with morbid obesity and a right leg amputation, experienced delays of up to an hour, leading to sitting in soiled briefs. Resident 57, diagnosed with lung and brain cancer, also faced extended wait times, prompting attempts to self-manage care. Interviews with staff revealed that call light response times were longer during periods of short staffing, which occurred occasionally. Staff members acknowledged that not all personnel assisted with answering call lights, contributing to the delays. The facility's administrator and director of nursing services confirmed the expectation for call lights to be answered within 20 minutes and recognized the failure to meet this standard for the affected residents. A review of the facility's staffing reports indicated that the facility did not meet mandatory state minimum CNA ratios on several occasions, particularly during the day shift. Additionally, the facility struggled to meet state bariatric staffing ratios on multiple dates. The staffing coordinator admitted difficulties in covering shifts, especially with last-minute call-offs, and the facility's leadership acknowledged the challenges in maintaining adequate staffing levels to meet state requirements.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received annual performance reviews, as evidenced by the lack of completed reviews for five randomly selected CNAs. During an interview and record review, it was discovered that the personnel profile records for these CNAs did not contain any annual performance reviews. Staff 2, the Director of Nursing Services (DNS), confirmed that if the reviews were not in the personnel profile folders, they had not been completed. Both Staff 1, the Administrator, and Staff 2 acknowledged this oversight, which placed residents at risk for receiving care from potentially incompetent staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of drugs and biologicals, as observed in three out of four medication carts. During an early morning observation, a diabetic/treatment cart was found to contain expired and improperly labeled medications, including Naloxone Nasal Spray and Lantus insulin without an open date. Additionally, an unlabeled bottle of insulin and a Humulin Kwik Pen with an expired open date were found. An unlabeled tube of Solosite Wound Treatment Gel was also discovered with an expired date. Furthermore, the medication cart was left unlocked and unattended outside the dining room, posing a risk to residents as several staff members and a resident walked past it. Further inspection revealed a medication storage card containing Lorazepam tablets for a resident who no longer had an order for the medication, along with three loose tablets of unknown ingredients. Staff confirmed these medications should have been destroyed. Additionally, multiple opened medicated creams and ointments were found without open dates on the labels, and staff was uncertain if open dates were required. The Director of Nursing Services (DNS) stated that staff was expected to adhere to the facility's policy for storing, labeling, and destroying medications and biologicals.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including dysphagia and pneumonitis. The resident, who had severe cognitive impairment and required substantial assistance for oral hygiene, had not been seen by a dentist since admission. Observations revealed the resident had jagged, broken, and decayed teeth, along with thick accumulations of oral secretions. A family member noticed the buildup on the resident's teeth and reported it to the facility staff, but dental care was not provided. Staff interviews revealed that the resident's teeth were swabbed rather than brushed due to a choking risk, and the resident was not seen by a dentist during the last visit to the facility. The Director of Nursing Services confirmed the inaccuracy of the resident's MDS and acknowledged the need for dental care. The deficiency was identified as a failure to provide timely dental services, placing the resident at risk for unmet dental needs.
Failure to Implement Compression Stocking Order for Resident with Edema
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with edema, as observed during a survey. The resident, admitted in November 2024 with conditions including deep vein thrombosis, atrial fibrillation, and high blood pressure, reported discomfort due to swelling in the legs. Despite a provider's order for compression stockings issued approximately four weeks prior, the resident did not receive them, and they were not observed on the resident's lower extremities. A registered nurse was unaware of the order, but located a progress note from December 6, 2024, indicating an order for Tubigrip, a form of compression dressing. The LPN Resident Care Manager acknowledged that the order had not been followed up on or implemented due to an oversight. The Director of Nursing Services stated that she expected provider orders to be processed and implemented.
Failure to Maintain and Support Resident's BIPAP Machine
Penalty
Summary
The facility failed to ensure proper respiratory care and maintenance of equipment for a resident diagnosed with sleep apnea who utilized a BIPAP machine. The resident was admitted with diagnoses including anxiety and depression, and the care plan indicated the need for a CPAP/BIPAP machine, which required regular cleaning. However, observations revealed that the BIPAP machine was dusty, and the tubing and mask were improperly stored in a drawer under magazines and a cracker box. The resident reported that staff did not clean the device or ensure it had distilled water, and there was no evidence of a physician's order for the BIPAP machine in the clinical record. Staff interviews confirmed that the resident used the BIPAP machine at night, but there was inconsistency in the cleaning responsibilities, with night shift staff reportedly responsible for cleaning. Despite this, the machine remained dusty, and there was no distilled water available. The RNCM acknowledged the lack of orders for the BIPAP machine and the inadequate cleaning of the equipment. This deficiency placed the resident at risk for breathing complications due to the improper maintenance and oversight of the respiratory equipment.
Failure to Administer Medications and Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to administer medications and ensure accurate completion of communication forms for a resident requiring dialysis. The resident, diagnosed with end-stage renal disease and diabetes, was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. Despite physician orders for specific medications to be administered before dialysis, the resident only received a pain medication prior to leaving the facility. Staff members confirmed that the resident's other morning medications were not administered until after returning from dialysis, which was contrary to the prescribed schedule. Observations and interviews revealed that the resident routinely left for dialysis without receiving the necessary medications, which were intended to be given before the procedure. Staff members, including LPNs and a CMA, acknowledged that the medications were either marked as administered or noted as the resident being out, despite not being given at the correct times. This practice was not known to the RNCM and DNS, who expected staff to seek clarification on medication administration for dialysis days. Additionally, the facility failed to ensure the accuracy and completion of Pre/Post Dialysis Communication forms. The forms were often inaccurate, incomplete, or not returned from the dialysis center. Staff members admitted to inconsistencies in the forms, with two different versions being used, and acknowledged that the forms were not always transcribed or uploaded into the electronic system as required. The RNCM and DNS were unaware of these issues, indicating a lack of oversight in the communication process for dialysis care.
Failure to Address Pharmacist Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were addressed for a resident reviewed for unnecessary medications. The resident was admitted with a diagnosis of insomnia and was prescribed Melatonin 1 mg at bedtime. In November, the pharmacist recommended increasing the dosage to 3 mg due to the resident's limited sleep duration of one to four hours per night. However, there was no indication in the clinical record that this recommendation was addressed. Interviews with staff revealed that the facility did not receive a response from the resident's provider regarding the pharmacist's recommendation, and it was noted that the provider did not consistently respond to such recommendations, causing delays in follow-up.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to ensure that waste was properly contained in dumpsters and that the garbage storage area was maintained in a sanitary condition. During an observation, the outside dumpsters adjacent to the kitchen door were found uncovered, with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters. This situation was acknowledged by the Dietary Manager, who noted that the garbage collection usually occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed that the facility's policy required garbage to be contained within the dumpsters with lids closed and the area around the dumpsters to be clear of garbage bags and debris to limit accessibility to pests. He stated that an additional dumpster was being used to contain all of the garbage and that staff had been educated on the importance of keeping the garbage in the dumpsters with the lids closed. The Director of Nursing Services also stated that she expected the facility's garbage to be contained in the dumpsters.
Failure to Follow Infection Control Practices for Residents with Special Needs
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to a risk of cross-contamination. Resident 36, who has severe cognitive impairment and requires significant assistance for toileting hygiene, was observed with a soiled brief. Staff 35, a CNA, entered the resident's room without donning the required personal protective equipment (PPE) such as a gown, despite the posted instructions for enhanced barrier precautions due to the resident's PEG tube. Staff 35 admitted to not wearing a gown while providing care, which included changing the resident's brief and linens. Similarly, Resident 49, who has a Foley catheter, did not have instructions for enhanced barrier precautions posted outside their room. Staff 41, another CNA, provided hands-on care, including a brief change, wearing only gloves and no additional PPE. The facility's infection preventionist and administrator confirmed that enhanced barrier precautions were necessary for Resident 49 due to the presence of the Foley catheter, but these precautions were not followed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually. This deficiency was identified for five randomly selected staff members. During an interview and record review, it was revealed that the personal profile records for these staff members showed no completed training hours. The Director of Nursing Services (DNS) confirmed that if no records were found in the personal profile folders, the training was not completed. Both the Administrator and the DNS acknowledged the lack of completion of the required training hours for the staff members involved.
Failure to Provide Transfer Notices with Appeal Rights
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives when residents were transferred to the hospital. This deficiency was identified for two residents who were hospitalized. Resident 80, admitted in February 2024 with a stroke and swallowing difficulties, was transferred to the hospital on October 5, 2024. A review of Resident 80's health record showed no evidence of a transfer notice with appeal rights being provided in writing to the resident or their representative. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024. Again, there was no documentation in Resident 81's health record indicating that a transfer notice with appeal rights was provided in writing. Staff 2, the Director of Nursing Services (DNS), confirmed that transfer notifications with appeal rights were not being provided to residents or their representatives upon hospital transfer, despite it being her expectation that such notifications should be given.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide two residents with a written bed hold notification, including information on reserved bed hold payment, at the time of their transfer to the hospital. Resident 80, who was admitted in February 2024 with a stroke and difficulty swallowing, was discharged to the hospital on October 5, 2024, without receiving the required written notice. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024, without receiving the written bed hold policy. Staff 2, the Director of Nursing Services (DNS), confirmed that the written bed hold policy was not provided to either resident or their representatives at the time of their hospital transfers.
Failure to Provide Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to provide bed rails needed for bed mobility for a resident, which placed the resident at risk of activities of daily living (ADL) decline. The resident, who was admitted with chronic kidney disease and required dialysis, was cognitively intact with a BIMS score of 15 and needed moderate assistance with bed mobility. Upon admission, the resident requested bed rails to assist with bed mobility, as documented in a nursing admission note. Despite this request, the resident had to use the headboard to reposition themselves and waited several weeks before bed rails were installed. A public complaint was filed on 6/28/24, indicating the resident's request for bed rails. A grievance form filed by the resident on 5/29/24 reiterated the request for bed rails. Staff interviews revealed that an LPN recalled the resident's request and stated that an assessment was completed, and a physician's order was requested. However, the Director of Nursing Services (DNS) stated that a bed rail assessment was not completed, although a physician order was initiated on 5/29/24. The facility administrator acknowledged the delay in providing the bed rails, which were not installed until 5/29/24, despite the resident's request at the time of admission.
Failure to Permit Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization or therapeutic leave, exceeding the bed-hold policy, for one of the four sampled residents reviewed for discharge. The resident, who was admitted in December 2023 with diagnoses including absence of the right foot, heart failure, and cocaine abuse, was noted to be homeless and staying in her/his car or motels. On March 4, 2024, a progress note indicated the resident was out of the facility at her/his mother's house, and by March 5, 2024, staff had left a voice message for the resident to return. On March 9, 2024, the resident returned to the facility early in the morning after being out since March 3, 2024, and was informed by a staff RN that she/he was discharged per facility policy. Despite this, the resident went to her/his previous room and went to bed, prompting staff to call the on-call manager. A public complaint filed on May 3, 2024, alleged that upon the resident's return, her/his belongings were locked up, and she/he was informed of being discharged against medical advice (AMA) and was escorted out of the facility. The facility's administrator confirmed that the resident was not permitted to return after being late from therapeutic leave.
Failure to Provide Meal During Resident Discharge
Penalty
Summary
The facility failed to ensure that meals were provided for a resident during discharge, which was identified as a deficiency. Resident 5, who had been admitted to the facility in December 2023 with a diagnosis of hypertension, was discharged on January 11, 2024, to another state. The discharge instructions indicated that the resident was to be transported to a new nursing facility, with an expected travel time from 10:15 AM to 5:30 PM. However, there was no indication that a meal was ordered or provided for the resident during this extended transport. Staff 10, a CNA, confirmed that the resident was sent out by medical transport without a meal. The facility administrator, Staff 1, acknowledged that the staff did not send a meal with the resident for the transport.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide timely optometry services for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan, dated April 5, 2022, indicated the presence of cataracts in both eyes and included an intervention to refer the resident for an eye exam. Despite this, a progress note from June 17, 2023, revealed that a staff member had discussed scheduling a vision appointment with the resident, but there was no documentation of any appointments being made. The resident reported on July 9, 2024, that they had requested an eye exam since admission, but the facility only recently scheduled an ophthalmology appointment. A staff member acknowledged on July 17, 2024, that the facility had not made a timely vision appointment for the resident after their admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan in April 2022 indicated dental care needs due to being edentulous, with an intervention to obtain a dental consult. Despite the resident requesting a dental exam in August 2022, and a progress note in June 2023 indicating a discussion about scheduling a dental appointment, no appointments were documented until new orders were issued in August 2023. Observations in July 2024 confirmed the resident was missing most natural teeth and had requested dentures since admission, but the facility had not scheduled any dental appointments. Staff acknowledged the delay in making a timely dental appointment for the resident.
Failure to Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to re-evaluate elopement risks and modify care plan interventions for a resident with cognitive impairment and aphasia, leading to an immediate jeopardy situation. The resident, admitted in April 2024 with a history of stroke, dysphagia, and severe cognitive impairment, exhibited wandering and exit-seeking behaviors. Despite being identified as an elopement risk, the resident's care plan did not adequately address these behaviors, and staff failed to consistently document or communicate the resident's exit-seeking tendencies. On June 12, 2024, the resident eloped from the facility, having been last seen at 6:30 AM. Staff initiated a search and contacted law enforcement when the resident was not found. Interviews revealed that staff were aware of the resident's elopement risk but did not consistently chart or communicate these behaviors. The resident had previously been observed unsupervised in the parking lot, and staff had overheard the resident expressing a desire to leave. However, these incidents were not adequately addressed in the care plan or communicated among staff. The facility's failure to re-evaluate the resident's elopement risk and modify care plan interventions resulted in the resident's elopement and placed other residents at risk. Staff interviews indicated a lack of awareness and communication regarding the resident's behaviors, contributing to the deficiency. The facility's Wandering and Elopement policy was not effectively implemented, as staff did not consistently monitor or document the resident's exit-seeking behaviors, leading to the resident's continued missing status.
Removal Plan
- All current residents with cognitive impairment will have an elopement risk assessment completed
- Residents with an identified elopement risk will have care plans reviewed for effective interventions and updated as needed
- Behavior monitors will be created and/or updated to reflect identified elopement risks and interventions
- Weekly audits to be conducted of elopement risks for care plan, interventions and behavior monitor
- Audits will be brought to QAPI for review
- Nursing staff were to update themselves regarding wandering protocol at the start of every shift
- Residents with known elopement/wandering risks observed to be exit seeking would be monitored by staff, who were not to leave the resident and tell other staff to alert the charge nurse
- Nurses were to chart any type of exit seeking behaviors
- At the beginning of each shift, all care staff will do walking rounds and all residents must have visual checks completed by staff
- Elopement risk assessments will be completed on admission, quarterly and with any behavioral changes
Lack of QAPI Plan and Program
Penalty
Summary
The facility failed to develop and present a Quality Assurance and Performance Improvement (QAPI) plan to the State Survey Agency (SSA) and did not provide documentation or evidence of an ongoing QAPI program. This deficiency was identified through interviews and record reviews. The facility's administrator, referred to as Staff 1, acknowledged the absence of a QAPI plan and program during the survey.
Failure to Conduct Quarterly QAA Meetings and Involve Medical Director
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) committee meetings and did not include the Medical Director in the quality assurance process. This deficiency was identified through interviews and record reviews, which revealed a lack of evidence or documentation supporting the occurrence of these meetings. Staff 1, the Administrator, acknowledged that the QAA committee had not met quarterly and confirmed the absence of the Medical Director's involvement in the quality assurance activities. This oversight placed residents at risk of not receiving the necessary care and services for optimal outcomes.
Latest citations in Oregon
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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