Chehalem Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Newberg, Oregon.
- Location
- 1900 E. Fulton Street, Newberg, Oregon 97132
- CMS Provider Number
- 385199
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Chehalem Post Acute during CMS and state inspections, most recent first.
Two residents experienced multiple room changes without receiving the written advance notice required by facility policy, which mandates written notification with reasons for any room or roommate change. One resident with quadriplegia and aphasia had a designated family responsible party who was not given written notice before a room move, as confirmed by both the family member and facility leadership. Another resident with dementia and cognitive communication deficits underwent several room changes, with no documentation of written notification in the clinical record, and the Administrator acknowledged that written notices were not provided in these instances.
Two dependent residents did not receive scheduled showers needed to maintain hygiene and dignity. One resident with quadriplegia, aphasia, and severe cognitive impairment was care planned for staff-assisted showers but, over multiple scheduled opportunities, received only a few showers, some bed baths, and no documented make-up showers for several missed or refused shower days, despite family complaints of strong body odor and greasy hair and staff acknowledgment that showers were important. Another resident with diabetes, metabolic encephalopathy, and bowel and bladder incontinence, who preferred showers and was scheduled for twice-weekly bathing, had only one shower documented over about a month, with no evidence of additional offers when showers were missed. Staff interviews revealed that residents rarely refused showers, that agency CNAs frequently documented refusals without offering showers, and that heavy reliance on agency staff and workload issues, especially on evening and weekend shifts, led to showers not being completed as scheduled.
A former LPN continued to receive confidential resident information, such as names, room numbers, and admission details, through a phone app for about a month after leaving employment. The administrator confirmed the oversight, as the app used for staff communication was not updated to remove the former employee, resulting in a breach of resident privacy.
A facility-wide assessment was found to be incomplete and lacking accurate information on staffing needs, resident ADL assistance, transmission-based precautions, resident demographics, and agency staff usage. The Administrator confirmed the assessment was not comprehensive and did not address these critical areas.
The facility did not ensure its QAPI program addressed multiple quality concerns, including insufficient staffing, unresolved grievances, unmet memory care regulations, medication and pharmacy service delays, construction-related disruptions, inadequate infection control, and lack of timely lab services. Leadership acknowledged these issues were not recognized or acted upon by the QAPI process.
The facility did not have an RN on duty for at least eight consecutive hours on multiple occasions, as confirmed by staff records and administrator acknowledgment.
The facility did not have a qualified infection preventionist overseeing the infection prevention and control program for an extended period. Documentation and staff interviews confirmed a gap of several months without a certified infection preventionist, and a registered nurse assigned to the role did not receive required training before being terminated.
The facility did not maintain resident privacy and confidentiality when a terminated staff member continued to receive confidential information through a phone app, and during a facility-wide flooring replacement, two residents received personal care without adequate privacy due to insufficient dividers. Staff and residents reported concerns about the lack of privacy, and the available measures were not sufficient to protect resident dignity during personal care.
The facility did not complete reference checks for three newly hired staff members, including an LPN and two CNAs, as required by its abuse prevention policy. Human Resources and the Administrator confirmed that reference checks had not been performed for new hires since a change in ownership, contrary to facility policy.
The facility did not maintain adequate nursing staff to meet resident care needs, resulting in prolonged call light response times, delayed medication administration, and incomplete care, especially for residents with high acuity and those requiring two-person assistance. Both residents and staff reported frequent short staffing, with management aware of the ongoing issues but not providing timely solutions.
Annual performance reviews were not completed for three CNAs who had been employed for over a year. When requested, no documentation of these reviews was provided, and the DNS confirmed that the required evaluations had not been conducted within the past 12 months.
The facility did not ensure timely procurement and administration of routine medications, resulting in multiple residents missing or receiving late doses of essential medications such as pain relievers, antihypertensives, and antidepressants. Delays were caused by pharmacy communication issues, staff not verifying orders, and workflow disruptions during a renovation project, with staff shortages further contributing to the problem.
Surveyors observed a treatment cart and a medication cart left unlocked and unattended in the hallway near the nurses station. The treatment cart contained insulin, creams, and other supplies, while the medication cart contained resident medications. In both cases, an LPN admitted to leaving the cart unsecured, and the DON confirmed that carts are expected to be locked when unattended.
Staff failed to perform proper hand hygiene during meal service, did not implement a required water management program for water-borne pathogens, and did not follow CDC Enhanced Barrier Precautions for two residents with indwelling catheters, resulting in improper disposal of PPE outside resident rooms.
Two residents received psychotropic medications, including trazodone and quetiapine fumarate, without being informed of the risks and benefits or providing consent. Staff and nursing leadership confirmed that the required discussions and documentation of informed consent did not occur prior to administration.
A resident with dementia had a critical low hemoglobin level identified by lab testing, but the result was not communicated to the ordering practitioner due to technical and communication issues. The critical value remained unreviewed for several days, during which the resident developed significant symptoms and was later hospitalized.
A resident with severe cognitive impairment and a diagnosis of dementia was offered and refused a COVID-19 vaccine without the facility contacting or obtaining consent from the resident's Power of Attorney, despite facility policy requiring representative consent for residents unable to make their own medical decisions.
Two residents experienced deficiencies in environmental cleanliness and room repair, including a bathroom with dried feces, an electric outlet with exposed wires, and a window with missing trim and jagged edges. Housekeeping and maintenance staff were aware of these issues, and residents and family members reported ongoing concerns about cleanliness and safety.
A resident with quadriplegia and bowel incontinence did not have their preference for suppositories over oral medications documented in their care plan. As a result, agency staff were unaware of this preference and administered oral medications, causing the resident distress. Staff interviews confirmed the omission and the resident's ongoing requests for suppositories first.
A resident with schizophrenia and major depressive disorder received the wrong antidepressant for 25 days after an LPN transcribed a provider order for Celexa, despite the resident not previously being on that medication. The original medication, escitalopram, was discontinued and replaced in error, and the mistake was not identified until a psychotropic drug review.
Three residents experienced deficiencies in medication management, including lack of bowel movement monitoring and administration of prescribed laxatives, failure to clarify and administer sliding scale insulin for elevated blood glucose, and a medication transcription error resulting in the wrong antidepressant being given for several weeks. Staff interviews and record reviews confirmed that required monitoring, documentation, and order clarifications were not performed.
A resident with dementia experienced an unwitnessed fall. Although staff checked vital signs, assessed for injuries, and started neuro checks, a required fall assessment was not completed, as later acknowledged by the DNS.
A resident with diabetes had a physician order for a stool sample to rule out c-diff. Staff collected the sample but mislabeled it with another resident's name, requiring a new sample to be obtained and causing a delay in lab results.
A resident with diabetes and heart failure, who was cognitively intact, was not given a pneumococcal vaccine despite providing verbal consent after education from the Infection Preventionist. The vaccine was not administered due to lack of follow-up.
The facility did not consistently post accurate and complete daily nurse staffing information, with several days showing missing or incorrect data regarding census and staff numbers. This was acknowledged by the administrator after review.
A resident with Alzheimer's and paranoid schizophrenia kicked another resident's walker, causing a fall and serious injury. Despite known behavioral issues, the facility failed to adequately monitor or separate the residents, leading to the incident. Staff were unaware of the need for increased supervision, resulting in a deficiency in resident safety.
A resident with dementia and visual disturbances was moved to a different room without prior written notice to the resident or their family, leading to increased anxiety and aggression. The facility's administrator confirmed the lack of notification and documentation regarding the room change.
A facility failed to follow care plan interventions for a resident requiring two-person assistance with a gait belt for transfers, leading to a potential risk of injury. An agency CNA attempted a one-person transfer, contrary to the care plan, resulting in the resident being returned to bed unsuccessfully. The resident later reported being dropped, complained of pain, and was diagnosed with a distal femur fracture at the hospital. Attempts to contact the CNA for further information were unsuccessful, and an LPN confirmed the transfer was not conducted correctly.
A resident with dementia and behavioral issues verbally and physically abused another resident during a bingo activity, resulting in a small bruise and feelings of abuse. The incident was acknowledged by the facility's administrator and DNS.
Failure to Provide Required Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide written advance notice of room changes to residents or their responsible parties, as required by the facility’s Room/Roommate and Change Notification Policy dated 8/1/24. That policy states residents have the right to receive written notice, including the reason for the change, before a room or roommate change occurs. For one resident admitted in 7/2025 with quadriplegia and aphasia, the admission profile/face sheet identified a family member as the responsible party. The clinical record showed this resident was moved to a different room on 8/21/25, but progress notes from 7/2025 through 9/2025 contained no documentation that written notification of the room change was provided to the responsible family member. During interview, the family member stated she did not receive written notification before the move, and the DNS and Administrator confirmed that no written notification had been provided. A second resident, admitted in 2/2025 with dementia and cognitive communication deficits, was identified as their own responsible party. The census showed this resident had multiple room changes on 12/20/25, 12/22/25, 12/30/25, and 1/3/26. On interview, the resident’s communication was unintelligible and responses unreliable when asked about the room changes. Review of the clinical record revealed no documentation of written notification for any of these room changes. The Administrator reported that residents or their responsible parties should receive written notification of room changes prior to being moved and confirmed that no written notifications were provided for this resident’s room changes.
Failure to Provide Scheduled Showers and Hygiene Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received showers as needed to maintain personal hygiene and dignity, contrary to its Activities of Daily Living policy requiring necessary services for grooming and hygiene. One resident with quadriplegia, aphasia, severe cognitive deficit, and total dependence for bathing was care planned to receive one-person total assistance for showers, but the care plan did not specify shower frequency. Bathing task logs for a one‑month period showed this resident was scheduled for showers twice weekly on Wednesdays and Saturdays, with 10 shower opportunities. The resident received showers on only four of those dates, two bed baths on two dates, and had no documented showers or make‑up showers on three Saturdays and one additional date when a shower was refused. There was no evidence in the clinical record that missed showers were made up, and a family grievance documented concerns about strong body odor and greasy hair and face, as well as a request to increase shower frequency. Interviews with CNAs and nursing staff confirmed that the resident was dependent on staff for showering, usually did not refuse showers, and that the expected practice was to make up missed showers later the same day or the next day, and to offer a bed bath if a shower was refused. Staff reported that showers were important for this resident due to sweating, smelly hair, and oily skin. Staff also acknowledged that showers were not consistently completed, particularly on Saturdays, and attributed this to heavy reliance on agency CNAs. The Assistant DNS/Resident Care Manager and DNS were aware that scheduled showers were missed during the review period, and observations over several days showed the resident in bed or in a Geri chair with oily facial skin. A second resident with diabetes, metabolic encephalopathy, bowel and bladder incontinence, and total dependence on staff for bathing was care planned to receive showers twice weekly and as necessary, with a preference for showers. The shower schedule listed this resident for Wednesday and Saturday evening showers, but bathing task logs over a one‑month period showed only one documented shower. Progress notes contained no evidence of additional shower opportunities when showers were refused or not provided. During observations, the resident was noted in bed with greasy hair and wearing a gown, and reported not being showered regularly, estimating the last shower was about a month prior, and stating that staff had not offered showers in a long time and that refusals were rare. CNAs confirmed the resident was frequently soiled, rarely refused showers, and that agency CNAs often documented refusals without actually offering showers. Staff also reported that scheduled showers were often not completed due to workload, staffing patterns, and the need for two staff and a mechanical lift for this resident, and the DNS and regional clinical leader confirmed that the last documented shower date for this resident was not acceptable.
Failure to Protect Resident Record Privacy After Staff Termination
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records by continuing to send confidential resident information to a former staff member, an LPN, via a phone application after her employment had ended. Documentation confirmed that the former LPN's last day at the facility was 6/19/25, yet she continued to receive private data, including resident names, room numbers, new admissions, and behavioral information, for approximately one month after her departure. The administrator acknowledged that the phone app used for internal communication was not updated to remove the former staff member, resulting in the ongoing disclosure of sensitive resident information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment necessary to ensure competent care for residents during both routine operations and emergencies. Review of the facility's assessment dated 3/19/25 revealed it was not comprehensive and lacked accurate information in several key areas, including how the assessment was used to address staffing needs and competencies, the percentage of residents on transmission-based precautions, the number of residents requiring assistance with activities of daily living (ADLs) based on average census, the ethnic, cultural, and religious makeup of the resident population, and the high usage of agency staff. During an interview, the Administrator acknowledged these deficiencies and confirmed that the assessment did not contain accurate or complete information in the specified areas. No additional information was provided.
Failure to Implement Effective QAPI Program to Address Quality Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively implemented action plans to address identified quality deficiencies. The QAPI policy outlined a systematic, comprehensive, and data-driven approach, but interviews and record reviews revealed that the program did not recognize or address several significant concerns. These included insufficient staffing based on resident acuity, unresolved resident grievances related to staffing, unmet regulatory requirements for the memory care unit, delays in residents receiving medications, lack of pharmacy services, issues caused by facility construction such as resident displacement and loss of privacy, inadequate infection control practices not aligned with CDC guidelines, delays in lab services, and the absence of an Infection Control Preventionist for a period of time. These deficiencies were acknowledged by facility leadership during interviews.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present for at least eight consecutive hours on six specific days, as identified through a review of Direct Care Staff Daily Reports. The dates without required RN coverage were 7/20/24, 9/16/24, 9/28/24, 1/4/25, 1/5/25, and 2/15/25. This deficiency was acknowledged by the facility administrator during interviews conducted on 3/26/25. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
Surveyors determined that the facility failed to have a qualified and trained infection preventionist responsible for the infection prevention and control program. Documentation provided showed that the previous infection preventionist's employment ended on 1/5/24, and the next infection preventionist did not start until 10/29/24, resulting in a gap of 298 days without a certified infection preventionist. During this period, a registered nurse was asked to serve as the infection prevention nurse but did not receive any education or training for the role and was terminated before the new infection preventionist began. Facility staff confirmed that there was no infection preventionist in place during this time.
Failure to Ensure Resident Privacy and Confidentiality During Staff Termination and Facility Construction
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records and personal care for two residents and did not ensure the security of its record system. After a staff member was terminated, she continued to receive confidential resident information, including admissions, discharges, and updates on resident conditions, via a phone application for nearly a month post-termination. The Director of Nursing Services (DNS) acknowledged that the expectation was for terminated staff to be removed from such communications immediately upon their last day of employment, but this did not occur. During a facility-wide flooring replacement, all residents were displaced from their rooms and relocated to common areas such as the main dining room, therapy room, and living room. During this period, there was inadequate privacy for residents while personal care was provided. Makeshift dividers using IV poles and blankets were used, but there were not enough to provide privacy between each resident. Staff reported that dividers were primarily used to separate genders and around commodes, but not between individual residents, resulting in residents receiving personal care and using bedside commodes without adequate privacy from others in close proximity. Both residents involved were cognitively intact and reported a lack of privacy during their stay in the therapy room. Staff confirmed that concerns about privacy were raised and communicated to the administrator, but the available resources were insufficient to ensure privacy for all residents during personal care. The administrator and DNS both stated that the expectation was for privacy to be maintained at all times, but this was not achieved during the construction period.
Failure to Complete Required Employee Reference Checks During Hiring
Penalty
Summary
The facility failed to implement its abuse prevention policies and procedures regarding employee screening for three newly hired staff members. According to the facility's abuse policy, the screening process for potential employees requires contacting previous employers to obtain employment history, including dates of service, positions held, performance history, and any history of abuse or neglect. During a review of three randomly selected new hires, it was found that no reference checks were completed for these staff members. Both the Human Resources staff and the Administrator confirmed that reference checks had not been conducted for new hires since a change in facility ownership, despite the policy requirement.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of its residents, as evidenced by multiple documented instances of delayed response to call lights, unmet care needs, and insufficient staff coverage. Resident council notes and grievances indicated repeated concerns about excessive wait times for call light responses, sometimes exceeding one hour, particularly after 6:00 PM and during nighttime hours. Specific incidents included residents being left on the toilet for extended periods and not receiving pain medications in a timely manner. The facility's own records showed that on several dates, CNA staffing did not meet state minimum requirements, and there were days with no RN coverage. Interviews with residents confirmed these issues, with several residents reporting waits of up to an hour or more for assistance, especially during shift changes and nighttime. Residents also reported not being checked on regularly by staff. Staff interviews corroborated these concerns, with CNAs, LPNs, and CMAs describing frequent short staffing, high resident acuity, and an inability to complete care tasks or administer medications on time. Staff reported that management was aware of the staffing shortages, but concerns were not adequately addressed, and staff often had to forgo breaks or stay late to complete care. The facility's resident population included a significant number of individuals requiring assistance with activities of daily living, such as dressing, bathing, toileting, incontinence care, and two-person transfers, as well as residents with high acuity needs including wound care, tube feeding, and diabetic care. Staff reported that the high acuity and insufficient staffing made it difficult to provide timely and adequate care, particularly in specialized units such as memory care. Management acknowledged awareness of the staffing issues but indicated that additional staffing was contingent on census increases or further justification.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews for three certified nurse aides (CNAs) who had been employed for over one year. Documentation of annual performance reviews and hire dates was requested from the Director of Nursing Services (DNS) for these staff members, but no annual performance reviews were provided to the survey team. The DNS acknowledged that these CNAs had not received performance reviews in the past 12 months, despite being employed at the facility for more than a year.
Failure to Timely Obtain and Administer Routine Medications
Penalty
Summary
The facility failed to obtain and administer medications to residents in a timely manner, resulting in missed and delayed doses for multiple residents. For one resident with a history of alcohol dependence and osteoarthritis, a physician ordered trazodone for sleep, but the medication was not administered until five days after the order was written. Staff interviews revealed that the delay was due to the pharmacy not having the order and nursing staff not verifying or requesting the medication promptly. Additionally, the same resident experienced a lapse in receiving prescribed oxycodone for pain, with documentation showing the medication was unavailable for a day, and staff confirmed challenges in accessing the emergency medication system and obtaining necessary authorization codes from the pharmacy. A separate incident involved multiple residents receiving late or missed medications during a flooring renovation project. On the day of the project, residents were displaced from their rooms, and there was a shortage of staff, with only two nurses available and no certified medication aides. Staff reported difficulty accessing a working computer, which delayed the start of the morning medication pass until late morning. As a result, morning medications for several residents, including blood pressure medications, pain medications, antidepressants, diuretics, and anticoagulants, were administered several hours late or held entirely because it was too late to administer them per physician instructions. Facility records and staff interviews confirmed that these delays and omissions in medication administration were directly related to staff shortages, workflow disruptions due to the renovation, and communication issues with the pharmacy. The affected residents had various medical conditions, including pain, hypertension, diabetes, urinary retention, and depression, and were dependent on timely medication administration for their ongoing care.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to secure medications and biologicals as required by policy and professional standards. On two separate occasions, surveyors observed a treatment cart and a medication cart left unlocked and unattended in the hallway near the nurses station. The treatment cart contained resident insulin, creams, and other treatment supplies, while the medication cart contained resident medications. In both instances, the responsible LPNs acknowledged leaving the carts unlocked and unattended. The Director of Nursing Services confirmed that the facility's expectation was for all medication and treatment carts to be locked when unattended.
Multiple Infection Control Deficiencies Identified
Penalty
Summary
Staff failed to perform proper hand hygiene during meal service on two of three halls reviewed. Observations showed a CNA retrieving and delivering meal trays to multiple resident rooms without sanitizing hands between rooms or after handling soiled items such as used coffee cups. The CNA acknowledged not completing hand hygiene as required, and the Director of Nursing Services confirmed that staff were expected to sanitize hands before and after entering resident rooms and passing meal trays. The facility did not have a water management program or conduct a risk assessment for water-borne pathogens, including Legionella, as required by CMS guidelines. Review of facility policies indicated that an annual risk assessment and water management program were expected, but the facility assessment showed no evidence of such activities. The Maintenance Director and Administrator both confirmed that no water management program or prevention plan was in place for the facility's main water system. Staff did not follow CDC guidelines for Enhanced Barrier Precautions for two residents with indwelling catheters and other risk factors. Signage indicated that enhanced barrier precautions were in place, but used PPE was consistently disposed of in garbage bins located outside the residents' rooms rather than inside, as required. Multiple staff members confirmed this practice, and the Infection Preventionist acknowledged that used PPE should have been discarded inside the resident rooms.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent prior to administration for two of five sampled residents. One resident, admitted with anxiety, was prescribed trazodone for a sleep disorder, but there was no documentation that the resident was informed of the medication's risks and benefits. Staff confirmed that this information was not provided. Another resident, admitted with anxiety and post-traumatic stress disorder, received quetiapine fumarate for anxiety without documentation of informed consent or evidence that the risks and benefits were discussed with the resident or their representative. The Director of Nursing Services confirmed that the medication was administered without obtaining consent.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
The facility failed to notify the ordering physician of a critical lab result for a resident with dementia who was admitted in 2024. On 10/9/24, laboratory tests revealed a critical hemoglobin level of 5.8 g/dL, which was reported to the facility the same day. The lab report indicated that a critical value was identified and the facility was contacted, but no staff were available to receive the result. The critical lab value remained unreviewed in the electronic health record due to a technical issue and a change in the phone system, and was not discovered by staff until 10/16/24. During this period, the resident developed abdominal pain, vomiting, and absent bowel tones, and was subsequently transported to the hospital. The delay in reviewing and communicating the critical lab result to the physician was confirmed through staff interviews and record review.
Failure to Obtain Resident Representative Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent from the resident representative for the administration of a COVID-19 vaccine for one resident with severe cognitive impairment. The facility's policy required that residents be offered COVID-19 vaccinations upon admission and as eligible, with consent obtained prior to or at the time of vaccination. The resident in question had diagnoses including dementia and adult failure to thrive, and was identified as having severely impaired cognition on the most recent MDS assessment. The clinical record showed that the resident was educated about, offered, and refused the COVID-19 vaccine, but there was no documentation that the resident's Power of Attorney and healthcare decision maker was contacted for education or consent. Staff confirmed that the resident representative was not contacted regarding the vaccine.
Failure to Maintain Cleanliness and Safe Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for two of three sampled residents. For one resident with hemiplegia, the shared bathroom was observed to have dried feces inside and outside the toilet bowl, with caked-on old feces between the bowl and tank, and feces splattered on the floor. Resident Council notes indicated ongoing issues with bathroom cleanliness and confusion among residents about which staff were responsible for cleaning. The resident and a family member confirmed the unsanitary condition had persisted for at least a day or two. The assigned housekeeping staff stated the bathroom was last cleaned the previous day but did not provide further explanation when shown the condition. The facility administrator acknowledged the bathroom was not clean at the time of observation. Additionally, the same resident's room had an electric outlet that was partially detached from the wall, exposing wires, with the resident's bed positioned in front of it and a device plugged in. Maintenance staff confirmed awareness of the issue, stating the outlet had been pulled from the wall for at least two months. Another resident's room was found to have a window with a large piece of bottom trim missing, leaving jagged edges exposed. Maintenance staff acknowledged the missing trim and exposed edges.
Failure to Develop Person-Centered Bowel Care Plan
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan that addressed a resident's specific preferences for bowel care. The resident, who has quadriplegia and is incontinent of bowel, was identified as being at risk for constipation and had a care plan that included a bowel regimen with medications and suppositories. However, the care plan did not specify the resident's preference for receiving a suppository before oral medications, despite this being a long-standing request. Multiple staff interviews confirmed that the resident preferred suppositories over oral medications and would become upset when this preference was not honored, particularly by agency staff who were unaware of the resident's wishes. The lack of documentation regarding the resident's bowel care preferences led to inconsistent care delivery, with agency staff administering oral medications instead of suppositories, contrary to the resident's expressed wishes. The resident's care plan was not updated to reflect these preferences, and staff acknowledged that this omission contributed to the resident's dissatisfaction and distress during care. The deficiency was identified through interviews with the resident and staff, as well as a review of the care plan and medical records.
Failure to Clarify Medication Orders Leads to Prolonged Medication Error
Penalty
Summary
Staff failed to adhere to professional standards for medication management when a resident with schizophrenia and major depressive disorder was involved in a medication error. The resident had been receiving escitalopram (Lexapro) 20 mg daily as documented in the medication administration record (MAR). On 3/4/24, a provider note indicated a plan to halve the dose of Celexa (citalopram), but the resident had not previously been on Celexa. The new order for Celexa 10 mg daily was transcribed by an LPN, and escitalopram was discontinued with the reason documented as a decrease to 10 mg. As a result, the resident received Celexa 10 mg daily for 25 days in error, due to a discrepancy between the provider order and the resident’s actual medication history. Nursing staff did not clarify the physician order, and the error was not identified until a psychotropic drug review.
Failure to Clarify and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents. For one resident with congestive heart failure, the care plan required daily monitoring of bowel movements and administration of Milk of Magnesia if no bowel movement occurred after three days. However, records showed two separate four-day periods without a bowel movement, during which no bowel medication was administered or documented as offered, accepted, or refused. Staff interviews confirmed that monitoring and documentation were lacking, and the care plan did not reflect the resident's history of refusing bowel medication. Another resident with diabetes was admitted with a new sliding scale insulin order that required staff to administer insulin and contact the physician if the capillary blood glucose (CBG) exceeded 300. The resident had a CBG of 327, but there was no documentation that insulin was given or that the physician was contacted to clarify the order or report the elevated CBG. The Director of Nursing Services acknowledged that the order was not clarified and the required actions were not taken. A third resident with schizophrenia and major depressive disorder experienced a medication discrepancy involving antidepressants. The provider ordered a dose reduction of citalopram (Celexa), but the resident had not previously been receiving this medication. Instead, the resident was on escitalopram (Lexapro), which was discontinued and replaced with citalopram per the new order. The resident received citalopram in error for 25 days due to a failure to clarify the provider's order, and the discrepancy was not identified until a psychotropic drug review. Staff interviews confirmed the error and lack of order clarification.
Failure to Complete Fall Assessment After Resident Fall
Penalty
Summary
The facility failed to complete a fall assessment for a resident with dementia who experienced an unwitnessed fall. On the date of the incident, a CNA reported the fall to the nurse, who then took the resident's vital signs, assessed for injuries, and initiated neuro checks. The resident was found to be confused but had intact skin and no immediate signs of bruising or injury. Despite these actions, a formal fall assessment was not completed for the incident, as confirmed by the Director of Nursing Services when requested at a later date.
Delay in Diagnostic Lab Services Due to Specimen Labeling Error
Penalty
Summary
The facility failed to provide timely diagnostic services for a resident with diabetes who was admitted in 2024. A physician order was received on 10/3/24 to obtain a stool sample to rule out Clostridium Difficile (c-diff). Staff initially collected the sample after the order was received, but mistakenly labeled it with another resident's name. As a result of this error, staff had to collect a new sample on 10/9/24, which delayed the laboratory results. The Director of Nursing Services confirmed that the order was not completed until 10/9/24, several days after the initial request.
Failure to Administer Pneumococcal Vaccine After Obtaining Consent
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to one of five sampled residents who was reviewed for immunizations. The resident, admitted with diagnoses including diabetes and heart failure, was found to be cognitively intact according to the most recent MDS assessment. The clinical record showed an undated pending consent for the Prevnar 20 pneumococcal vaccine. The Infection Preventionist reported that she had educated and offered the vaccine to the resident, who gave verbal consent, but did not follow up, resulting in the vaccine not being administered.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete daily nurse staffing information as required. A review of the Direct Care Staff Daily Reports over a period from January 1, 2025, through March 18, 2025, showed that on five separate days, portions of the required forms were either left blank or contained inaccurate information. The missing or incorrect data included the daily census and the number of working staff. This deficiency was confirmed by the facility administrator, who acknowledged the incomplete and inaccurate reports for the identified dates. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Prevent Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in a serious injury. Resident 13, who has Alzheimer's and paranoid schizophrenia, deliberately kicked Resident 14's walker, causing Resident 14 to fall and sustain a head laceration, contusion, and a fractured hip requiring surgery. This incident occurred while Resident 13 was visiting with a family member in the hallway, and no staff were present during the altercation. Resident 13 had a history of moderate cognitive impairment and behaviors such as agitation and suspiciousness, while Resident 14 had severe cognitive impairment and was known for physical and verbal aggression. Despite these known behaviors, the facility did not adequately monitor or separate the residents, leading to the altercation. Previous incidents between the two residents had occurred, including a physical altercation on a prior date, but interventions to prevent further incidents were insufficient. Staff members were not fully aware of the need to monitor or separate the residents, and there was a lack of communication regarding the residents' behaviors and necessary precautions. The facility's failure to supervise and protect the residents resulted in a preventable injury, highlighting a deficiency in the facility's ability to ensure resident safety and prevent abuse.
Failure to Notify Resident and Family of Room Change
Penalty
Summary
The facility failed to provide advance written notice to a resident or their responsible party prior to a room change, violating the resident's rights. Resident 10, who was admitted with diagnoses including dementia and visual disturbances and was receiving hospice services, was moved from room 17-2 to 21-2 without prior notification to the resident or their family. The resident's spouse, who was the responsible party, discovered the room change upon visiting and noted that the resident's behavior became more anxious and aggressive following the move. The facility's administrator confirmed that no notification was made to the resident or family before the room change, and there was no documentation in the resident's clinical record regarding the notification of the room move.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to adhere to care plan interventions for a resident requiring two-person assistance with a gait belt for transfers, leading to a potential risk of injury. The resident, admitted in March 2019 with diagnoses including spinal fusion and anxiety, was cognitively intact with a BIMs score of 15. On August 3, 2024, an agency CNA attempted to transfer the resident without a second staff member, contrary to the care plan. The CNA reported that the resident claimed to be a one-person stand and pivot transfer, but the transfer was unsuccessful, and the resident was returned to bed. The resident later reported being dropped on the floor, complained of pain, and was unable to lay flat, leading to a hospital transfer where a distal femur fracture was diagnosed. Hospital records did not indicate the cause of the fracture, and attempts to contact the CNA for further information were unsuccessful. An LPN confirmed the resident was not transferred correctly but could not confirm the cause of the fracture.
Resident Abuse Incident During Activity
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by another resident. Resident 3, who was admitted to the facility in 2024 with a diagnosis of obesity, was verbally and physically abused by Resident 4 during a bingo activity. Resident 4, who was also admitted in 2024 and had a diagnosis of dementia with behaviors, became agitated and kicked Resident 3 in the left foot three times while yelling profanities. This incident was documented in a facility Event Summary Report dated 1/30/24, which confirmed the verbal and physical abuse by Resident 4 toward Resident 3. Resident 3 reported feeling both physically and verbally abused, stating that Resident 4 kicked them multiple times and used derogatory language, including calling them a 'fat [expletive]'. Resident 3 also mentioned having a small bruise from the incident. Despite forgiving Resident 4, Resident 3 expressed that they could not forget the event. Resident 4, who was often confused and cognitively impaired, was unable to recall the incident. The facility's administrator and DNS acknowledged the findings of abuse related to this incident.
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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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