Corvallis Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Corvallis, Oregon.
- Location
- 160 Ne Conifer Blvd, Corvallis, Oregon 97330
- CMS Provider Number
- 385072
- Inspections on file
- 33
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Corvallis Manor during CMS and state inspections, most recent first.
Surveyors found that the facility did not properly investigate two separate incidents involving two residents. In one case, a resident with muscle weakness and unsteadiness was found on the floor near an electric wheelchair after an unwitnessed fall, but the facility’s investigation lacked witness statements, a root cause analysis, and documentation ruling out abuse or neglect. In the other case, a resident with muscle weakness and diabetes reported a missing phone through a grievance and to the police, yet there was no documented investigation into how the phone went missing, and staff later acknowledged that such an investigation should have occurred.
A resident with a history of hip pain and a fractured thigh bone did not receive prescribed narcotic pain medication on multiple occasions due to medication unavailability and communication breakdowns between staff, providers, and the pharmacy. Documentation showed the resident experienced severe pain while awaiting the medication, and staff acknowledged delays in reordering and escalating the issue.
Two residents experienced significant delays in receiving care due to insufficient nursing staff and poor communication. One resident waited over 50 minutes for medication for constipation, while another, who was bedridden, waited 45 minutes for incontinence care and was told to wait until after meals. Staff confirmed these delays and the administrator acknowledged the expectation for call lights to be answered within 15 minutes.
A resident dependent on staff for toileting, with a history of stroke and language deficits, was left alone on the commode despite a care plan and posted instructions requiring staff presence. The assigned CNA was unaware of the updated care plan due to an unupdated Kardex, resulting in the resident experiencing distress and filing grievances regarding unmet needs and delayed assistance.
A resident with complex regional pain syndrome and anxiety did not receive prescribed eye drops due to unavailability, and a physician-approved substitution was delayed. Staff were aware of the medication shortage and the resident's repeated requests, but the new order was not implemented promptly, resulting in unmet care needs.
A resident with a history of stroke and language deficits, identified as a fall risk and dependent on staff for toileting, experienced a fall from the commode after the call light was not placed within reach as required by the care plan. Staff confirmed the call light was attached to the bed and not accessible, and the investigation into the incident was incomplete.
Two residents suffered significant injuries when staff failed to properly use a mechanical lift and did not follow care plan interventions. One resident fell headfirst from a Hoyer lift due to an unsecured sling strap, resulting in multiple brain and spinal injuries. Another resident, who required a two-person assist, was injured when a staff member provided care alone and failed to remove a broken call light clip, causing a skin tear and multiple bruises. Staff interviews and records confirmed that required safety checks and care plan protocols were not followed.
A resident with dementia and weakness was found with unexplained bruising, swelling, and pain in multiple areas. Staff assessed the injuries and notified supervisors, but did not complete a Facility Reported Incident (FRI) form or report the injuries as required. This failure to report and document the injuries of unknown origin resulted in a deficiency related to abuse and neglect reporting protocols.
The facility did not maintain proper food temperatures during meal service, resulting in cold and unpalatable meals for two residents, including one with cirrhosis and another with diabetes and malnutrition. Staff acknowledged equipment issues and residents reported dissatisfaction with food quality, including meals being served cold and not meeting dietary needs.
The facility failed to follow physician orders and implement care protocols for several residents, including missed administration of nutritional supplements and medications, lack of documentation for blood sugar checks, improper medication administration routes, delayed wound care due to unavailable supplies, and failure to monitor or address bowel and urinary issues. Staff interviews confirmed lapses in care, lack of timely physician notification, and unfamiliarity with required procedures.
A resident with cognitive impairment and mental health diagnoses was allowed to keep multiple medications in their room without proper assessment, monitoring, or documentation by staff. Staff did not consistently review administration instructions or track which medications the resident accessed or returned, resulting in unsecured medications and a lack of oversight.
A resident with cognitive capacity reported a missing cell phone to staff on multiple occasions, but no grievance was filed or assistance provided, despite staff awareness of the issue. Facility records confirmed no grievance was submitted, and staff interviews revealed a lack of knowledge about the grievance process and forms.
A resident with anxiety and PTSD was admitted and assessed through PASARR Level II, which recommended a recliner chair to address discomfort from prolonged wheelchair use. The recommendation was overlooked, and the resident did not receive the chair, with staff later acknowledging they were unaware of the PASARR guidance.
Two residents who required assistance with ADLs did not receive necessary personal hygiene care. One resident was repeatedly observed with long facial hair despite requesting its removal, and another resident with diabetes had long, dirty, and jagged fingernails, with required nail care not completed as scheduled. Staff interviews revealed confusion about responsibilities and a lack of direct assessment.
A resident with diabetes and vascular dementia developed redness and swelling of the left big toe, which was not properly monitored or evaluated as ordered. Documentation of physician orders and wound care was lacking, and the resident was discharged without the scheduled physician assessment. Upon admission to another facility, the resident was found to have an infected ingrown toenail with significant symptoms, confirming the lack of appropriate foot care and monitoring.
Water temperatures in both resident bathrooms and the therapy gym were found to be excessively high, with measurements reaching up to 141.6°F. Several residents with significant care needs, including those dependent on staff for toileting and mobility, were exposed to these unsafe conditions. Maintenance staff were unable to explain the discrepancy between boiler settings and actual water temperatures, and staff interviews confirmed that the issue had not been previously identified or addressed.
A resident with incomplete quadriplegia and a history of UTIs was allowed to self-catheterize without staff assessment or observation of their technique or hand hygiene. Staff set up supplies but did not verify if the resident performed the procedure in a clean manner, and there was no documentation of education or assessment related to infection prevention.
A resident with ESRD requiring hemodialysis did not have consistent completion of required Pre- and Post-Dialysis Assessment forms, with some forms missing vital information or left blank, and daily weights were not obtained or documented as ordered by the physician. Nursing staff and the DNS confirmed these lapses in communication and documentation between the facility and the dialysis provider.
A resident with dementia and a documented history of multiple forms of abuse was not provided trauma-informed care, as their care plan lacked interventions addressing trauma despite staff awareness of PTSD and behavioral concerns. The care plan focused only on cognitive impairment, and the resident's expressed interest in behavioral health support was not acted upon.
A resident on hospice care with cancer was provided with bilateral half bed rails without a documented assessment to determine safety risks or necessity. Staff interviews confirmed that required evaluations were not completed before the rails were applied, and maintenance and hospice staff were unaware of any assessment being conducted.
A resident with PTSD, agoraphobia, and bipolar disorder exhibited ongoing depressive symptoms, irritability, and refusal of care. Despite a physician's recommendation for a geriatric psychiatric referral, no mental health evaluation was documented or provided. Staff interviews confirmed the resident's continued isolation and refusal of care, and facility leadership acknowledged the lack of behavioral health services.
Three residents did not receive proper medication management, including a delayed dose reduction for a mood stabilizer, continued administration of a discontinued pain medication, and administration of an anti-hypertensive despite low blood pressure readings. Staff were unaware of or did not follow standing orders, and medication changes were not implemented as ordered.
A resident with kidney failure was evaluated for a suspected UTI, but the final urine culture results were not communicated to the physician for six days. During this time, the resident was not started on antibiotics and was not monitored for complications. Staff interviews confirmed the delay and acknowledged that timely follow-up was expected.
A resident admitted with a stroke diagnosis had blood samples collected and sent for thyroid hormone testing as ordered by a prescriber. The results of these tests were not found in the clinical record, and a consultant pharmacist noted the absence. An LPN unit manager confirmed the samples were sent but could not explain why the results were missing or why follow-up did not occur.
Two residents with special dietary needs did not receive requested or ordered menu items, including pizza and oatmeal, due to staff inaction and lack of process training. One resident's pizza request was not fulfilled after preparation, and another resident did not receive oatmeal listed on their breakfast ticket. Facility leadership confirmed that residents should receive the food items listed on their tickets.
A resident with incomplete quadriplegia and a history of UTIs continued to receive daily prophylactic trimethoprim even after a urine culture showed resistance to this antibiotic. The resident was also treated with amoxicillin for the acute infection, but the original antibiotic was not discontinued, and no provider documentation justified its continued use. Staff interviews confirmed the lack of appropriate antibiotic stewardship in this case.
Two residents experienced deficiencies in their living environment, including a fan with dusty blades and unresolved maintenance issues such as a non-functioning phone and room light. Staff reported delays in completing work orders, and one resident's family had to use 911 dispatch to contact them due to the broken phone. An LPN also had to use a cell phone light to provide wound care because the room light was out.
A resident with a Stage 3 pressure ulcer did not receive prescribed wound care and wound vac changes as ordered, due to staff not performing the treatment over a weekend. Staff initially cited a lack of supplies, but the unit manager confirmed the necessary materials were available. The missed treatment was not documented, and the physician was not notified.
A resident admitted with diabetes and a surgical site infection did not receive prescribed mealtime insulin upon arrival due to delays in pharmacy order processing and delivery. Nursing staff and the pharmacist confirmed that the medication request was submitted after the immediate delivery deadline, resulting in the resident's insulin being administered several hours late.
The facility did not consistently implement infection control precautions for three residents, including inconsistent use of gowns during catheter care, ongoing shortages of plastic bags, paper towels, and soap that impeded proper disposal of soiled linens and hand hygiene, and staff failing to use required PPE when entering a room of a resident on contact precautions. These actions and inactions were confirmed by staff, residents, and direct observation.
The facility failed to maintain the low temperature dish machine, risking foodborne illnesses. The dish machine's wash cycle temperatures were inadequate, leading to the use of paper products for meal service. Staff reported inconsistent water temperatures affecting both dishwashing and resident showers. Despite this, management instructed continued use of the dish machine, relying on chemical sanitizers. The issue was not addressed promptly, although a new hot water heater was ordered.
The facility failed to provide properly textured diets for two residents, one with Alzheimer's and another with a history of stroke. Both required pureed diets, but their meals contained improperly processed food, posing risks for aspiration. Staff acknowledged the inadequacy of the non-commercial food processor and the need for additional training.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to resident call lights and unmet care needs. Observations and interviews revealed residents experiencing long wait times for assistance, with some waiting up to an hour. Resident Council Notes and witness statements confirmed ongoing staffing issues, particularly on weekends, affecting the timely provision of care.
Meals in the facility were not served at the proper temperatures, with eggs and milk failing to meet FDA guidelines. Residents and staff reported that meals were often late and cold, with one resident noting cold meals 75% of the time. A breakfast test tray confirmed the deficiency, with eggs at 91 degrees F and milk at 45 degrees F. Staff acknowledged the consistent issue of cold, unseasoned food served late.
The facility failed to maintain a safe and homelike environment in two resident rooms, where walls were in disrepair and baseboard coving was missing. This allowed outside air and cigarette smoke to enter the rooms, as confirmed by residents and staff. The issue was acknowledged by the facility's administrator and social service director, who noted that maintenance was aware and other rooms were similarly affected.
A resident with a left femur fracture was neglected in a facility, leading to a fall and subsequent hospital visit. The resident was found on the floor without footwear and with a soiled brief, having not been assisted with toileting for several hours. Staff interviews confirmed the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation substantiated neglect of care.
The facility did not staff an RN for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was confirmed through interviews and record reviews, revealing specific days in January, February, and March 2024 without adequate RN coverage. The Administrator and DNS acknowledged the issue, which placed residents at risk for unmet assessment needs.
A resident with a history of adverse reactions to COVID-19 vaccines was administered a booster without consent or discussion of risks and benefits. The facility's administrator and DNS confirmed the oversight, which went against the resident's and family's wishes.
Failure to Investigate Unwitnessed Fall and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete investigation of an unwitnessed fall for one resident. This resident was admitted with muscle weakness and unsteadiness on feet, and a public complaint alleged that the resident slept in a wheelchair and slipped out onto the floor. The facility’s unwitnessed fall investigation from that night documented that staff found the resident seated on the floor with the electric wheelchair positioned behind the resident at 12:20 AM, but the investigation lacked witness statements, a root cause analysis, and documentation confirming whether abuse or neglect had been ruled out. A registered nurse later stated she typically completed investigations for risk management but did not recall completing this unwitnessed fall investigation, and administration confirmed the investigation should have contained a root cause analysis, witness statements, and documentation excluding abuse or neglect. The deficiency also includes the facility’s failure to investigate a report of misappropriation of property for another resident. This resident, admitted with muscle weakness and diabetes, reported through a grievance that a phone that had been plugged in went missing around 1:00 AM, and a public complaint indicated the resident reported the missing phone to the police. Review of the clinical record showed no documentation of any investigation into the missing phone. The Social Services Director stated that an investigation should have been completed and noted the grievance focused on replacing the phone rather than determining how the phone went missing, and administration confirmed that an investigation into the missing phone should have been completed.
Failure to Provide Ordered Pain Medication Due to Communication and Refill Delays
Penalty
Summary
A resident admitted with right hip pain and a fractured thigh bone was prescribed hydrocodone-acetaminophen for pain management, to be administered every eight hours as needed for up to five days. Despite these orders, there were multiple documented instances where the resident did not receive the prescribed narcotic pain medication due to it being not available (NA) on the medication administration record (MAR). Specifically, doses were missed on several occasions, and staff notes indicated that the resident experienced severe pain during this period without access to the ordered medication. The deficiency was further compounded by communication issues between facility staff, the provider, and the pharmacy. Staff reported delays in reordering the medication and acknowledged that not all nurses had access to the provider communication system, making it the responsibility of Unit Managers to follow up on medication orders. The Director of Nursing confirmed that a refill for the narcotic medication was not sent to the pharmacy as required, and staff were expected to escalate such issues to management for resolution. These lapses resulted in the resident being without necessary pain medication for an extended period.
Delayed Response to Resident Needs Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents in a timely manner, as evidenced by delays in responding to call lights and providing necessary care for two residents. One resident with a history of stroke and dementia was left waiting for assistance for over 50 minutes after requesting medication for constipation, despite a care plan directing staff to check on the resident frequently. The delay was attributed to poor communication between staff and low nurse staffing, with an agency CNA failing to promptly relay the medication request to the appropriate staff member. Another resident, who was bedridden and dependent on staff for all self-care, experienced a 45-minute wait for assistance with a brief change after activating the call light. The resident reported being told by staff to wait until after meals for incontinence care, which made the resident feel undignified. Staff confirmed the resident's dependence and preference for being changed before meals, and acknowledged the ongoing nature of the concern. The administrator stated that call lights were expected to be answered within 15 minutes and recognized the need for further investigation into the delays.
Failure to Provide Required ADL Assistance During Toileting
Penalty
Summary
A dependent resident with a history of stroke and language deficits, who was cognitively intact and required two staff for toileting assistance, did not receive the necessary assistance with activities of daily living (ADLs). The resident was admitted with a care plan indicating the need for staff to remain present while on the commode. Despite this, a grievance was filed after the resident was left on the commode for 30 minutes, and the resident specifically requested not to be left alone. The care plan was revised to reflect this preference, and signage was posted in the resident's room instructing staff not to leave the resident alone on the commode. However, staff interviews revealed that the CNA assigned to the resident was unaware of the updated care plan and the requirement to remain with the resident, as the Kardex had not been updated following a recent fall. During a time when the CNA was assisting another resident, other staff were instructed to assist, but the resident still experienced a delay in assistance and reported distress. The facility's investigation into the grievances did not identify the staff involved, and there was an expectation from leadership that the Kardex should have been updated and a thorough investigation conducted.
Failure to Provide Timely Eye Treatment per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for eye treatments for one resident with complex regional pain syndrome and anxiety. Upon admission, the resident had a physician order for Optase (Glycerin) Comfort Dry Eye Solution to be applied twice daily. However, the medication was not available or on order from 7/2/25 through 7/10/25, and the resident did not receive the prescribed treatment during this period. Documentation shows that the resident repeatedly requested the eye drops, which increased their anxiety, and staff communicated with the pharmacy and the provider regarding the unavailability of the medication. On 7/7/25, a request was made to substitute the prescribed Optase with house stock Systane, and the physician approved this change. However, the new order for Systane was not implemented until 7/9/25, resulting in a delay in providing the necessary eye treatment. Staff interviews confirmed awareness of the medication shortage and the lack of a timely system to report or resolve missing medications. The delay in obtaining and administering the prescribed or substitute eye drops did not meet staff expectations and resulted in the resident's needs not being met as ordered.
Failure to Follow Fall Prevention Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan designed to prevent falls. The resident, who had a history of stroke and language deficits, was assessed as being at risk for falls and required the call light to be within reach at all times. Despite this, the resident experienced an unwitnessed fall from the commode, which was later attributed to the call light not being accessible. Staff interviews and documentation confirmed that the call light was attached to the resident's bed and not near the resident at the time of the incident. Further review revealed that the investigation into the fall was incomplete, lacking information about the cause or a conclusion. The resident reported being left on the commode for 30 minutes and specifically requested not to be left unattended. Multiple staff members, including an LPN and a CNA, acknowledged that the care plan was not followed, and facility leadership confirmed that the expected protocols were not adhered to in this case.
Failure to Prevent Accidents Due to Improper Use of Mechanical Lift and Non-Adherence to Care Plans
Penalty
Summary
The facility failed to ensure proper use of a mechanical lift (Hoyer) and adherence to care plan interventions, resulting in significant injuries to two residents. In one instance, a resident with Parkinson's disease and congestive heart failure, who was cognitively intact and required a two-person assist with a Hoyer lift, was being transferred from a raised bed to a shower chair. During the transfer, only three of the four sling straps were attached to the Hoyer, causing the resident to fall headfirst to the floor. The resident sustained a subarachnoid hemorrhage, intraparenchymal hemorrhage, scalp hematoma, and multiple compression fractures in the thoracic and lumbar spine. Staff interviews and observations confirmed that the sling was not properly secured, and the required safety checks were not performed prior to the transfer. In another case, a resident with dementia, weakness, and reduced mobility, who was severely cognitively impaired and required a two-person assist for turning and repositioning, suffered multiple injuries due to improper care. Staff failed to follow the care plan by attempting to provide care alone and not removing a broken, sharp call light clip from the resident's gown. This resulted in a skin tear on the resident's neck, bruising on the chest and right leg, and swelling and bruising on the left hand. Staff interviews revealed that the call light clip caused the skin tear when the blanket was pulled, and the resident was turned and dressed by a single staff member, contrary to the care plan. Both incidents were acknowledged by facility leadership, and documentation confirmed that the care plans and safety protocols were not followed, directly leading to the residents' injuries. The findings were based on observations, staff and resident interviews, and record reviews, which consistently indicated lapses in supervision and failure to prevent accident hazards as required.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for one resident who was admitted with dementia and weakness and required two-person assistance for turning and repositioning. On a specific date, staff observed the resident with bruising and discoloration on the right lower leg, swelling around the left hand, pain at the shoulder, and additional discoloration around the chest, none of which had been present the previous day. Staff members assessed the injuries and notified supervisory staff, but did not determine the cause of the bruising, and the resident was unable to describe how the injuries occurred. Despite the concerning findings, no Facility Reported Incident (FRI) form was completed for the resident. Staff involved acknowledged that an FRI form was not filled out, and one staff member stated she had never completed such a form before. The lack of timely reporting and documentation of the injuries of unknown origin constituted a failure to follow required abuse and neglect reporting protocols.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were properly maintained during meal service, resulting in meals being served cold and unpalatable to residents. Observations during a lunch meal service revealed that the oven temperature was not maintained, causing delays in food preparation. Multiple undelivered lunch trays were stacked on top of an insulated cart due to insufficient space, and when a test tray was sampled, the food items were not warm and the pork was tough to cut. Staff acknowledged that the kitchen lacked sufficient and functioning equipment to keep food hot and of acceptable quality. Two residents were directly affected by these deficiencies. One resident, with a history of cirrhosis of the liver and high blood pressure, reported that mashed potatoes were soupy, broth was overly salty, and meals intended to be hot were served cold. This resident expressed dissatisfaction with the meals and reported going to bed hungry due to poor food quality. Another resident, diagnosed with diabetes and protein-calorie malnutrition, also reported that hot food was sometimes served cold. Staff confirmed these concerns and verified that residents should receive hot food at appropriate temperatures.
Failure to Follow Physician Orders and Implement Care Protocols
Penalty
Summary
The facility failed to follow physician orders, implement bowel care, and properly treat and monitor skin conditions for multiple residents, resulting in unmet needs. For one resident with a PEG tube and NPO status, staff did not consistently administer a physician-ordered nutritional supplement (Juven) as documented in the MAR, with several missed doses and no explanation provided in the clinical record. Additionally, blood sugar checks were not consistently documented, and there was a failure to clarify conflicting orders regarding the administration route for loperamide, with staff administering the medication through the G-tube despite the order specifying oral administration. Another resident with diabetes received fast-acting insulin significantly before a meal was provided, contrary to best practice and the medication's instructions, and was not given a snack to mitigate the risk of hypoglycemia. Staff acknowledged the delay in meal service and the lack of a snack, and the resident reported eating over an hour after insulin administration. For a resident with kidney failure, staff did not monitor for signs and symptoms of a UTI as ordered after the resident declined antibiotics, and there was no documentation of monitoring for complications, with staff confirming the lack of follow-up and unclear processes for physician notification. A resident with heart failure and end-stage kidney disease experienced an absence of bowel movements for eight days without evidence of monitoring, assessment, or implementation of bowel care protocols, and staff delayed notifying the physician and failed to ensure bowel care orders were in place upon admission. Another resident with diabetes and a surgical site infection did not receive timely wound vac treatment due to unavailable supplies and staff unfamiliarity with the wound vac process, resulting in missed and delayed wound care as documented in the treatment administration record and staff interviews.
Failure to Assess and Monitor Safe Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and monitor a resident for safe self-administration of medication. The resident, who had diagnoses including somatization disorder and PTSD, was determined by staff to have cognitive impairment and was not considered a candidate for unsupervised self-administration of medications. Despite this, the care plan allowed the resident to check out one medication per day to keep in their room, with staff expected to review administration instructions and document the resident's acknowledgment. However, there was no documentation in the clinical record indicating that staff reviewed instructions or that the resident checked out medications as required. Observations revealed that the resident had multiple nasal sprays and supplements in their room, both on the bedside table and in a large plastic tote. The resident stated they were allowed to keep medications in their room if kept organized. Staff interviews confirmed that the resident was permitted to keep certain medications at the bedside during the day but that staff did not monitor which medications were taken or returned, nor did they ensure medications were properly secured. The DNS acknowledged that the resident was not capable of safe self-administration and that staff were expected to follow the care plan, but these procedures were not followed.
Failure to Act on Resident Grievance for Missing Property
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding missing property was acted upon in a timely manner. A resident admitted with fractures of the spine and pelvis, and documented as cognitively intact, reported her/his red cell phone missing on two occasions. Although the resident stated that staff were aware of the missing phone, no staff offered assistance to file a grievance, and the resident ultimately purchased a replacement phone. Review of facility grievance records showed no grievance form was submitted for the missing phone. Staff interviews confirmed awareness of the missing phone but revealed that no grievance was filed, and at least one staff member did not know where to locate a paper grievance form to assist the resident.
Failure to Implement PASARR Level II Recommendations for Resident with Mental Health Needs
Penalty
Summary
The facility failed to incorporate the PASARR Level II recommendations for a resident admitted with anxiety and post-traumatic stress disorder (PTSD). The PASARR Level II Mental Health Evaluation recommended providing a recliner-style chair for the resident, who reported discomfort from spending most of the day and night in a wheelchair and expressed a preference for sleeping in a recliner, as was their practice prior to admission. Despite this documented recommendation, the resident did not receive a recliner chair and had not received any updates regarding the request. Staff responsible for reviewing PASARR Level II results were unaware of the recommendations, and upon review, acknowledged that the recommendation had been overlooked.
Failure to Provide Required ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who required support. One resident, admitted with a history of stroke and muscle weakness and assessed as cognitively intact, required substantial to maximal assistance with personal hygiene. Despite care plans indicating the need for extensive support, this resident was repeatedly observed with significant facial hair and expressed a desire for its removal, stating that requests to staff had not resulted in the care being provided. Staff confirmed the presence of facial hair and acknowledged that it should have been addressed. Another resident, admitted with diabetes and also cognitively intact, required extensive assistance for bathing and hygiene, including diabetic nail care to be performed every two weeks. Observations revealed this resident had long, dirty, and jagged fingernails, and documentation showed that scheduled nail care was not completed as required. Staff interviews indicated confusion regarding responsibility for nail care, with CNAs and nurses each deferring to the other, and no direct assessment of the resident's nails was performed by the nurse responsible. The lack of proper nail care was confirmed by both observation and documentation.
Failure to Provide Appropriate Foot Care and Monitoring
Penalty
Summary
A resident with diabetes and vascular dementia was admitted to the facility and later developed redness and swelling of the left big toe, which was noted during an alert assessment. The area was cleansed, and the physician was notified, with instructions to monitor and provide supportive care. The resident was scheduled for a physician evaluation, but there was no documentation of monitoring or evaluation of the toe in the clinical record. Staff reported receiving a physician order for Epsom salt soaks, but no such order or wound evaluation was documented. The resident was subsequently discharged to another facility without evidence of the toe being evaluated by the physician as scheduled. Upon admission to the new facility, the resident was found to have an ingrown toenail with signs of infection, including increased drainage, pain, redness, inflammation, and eschar. The wound was measured and assessed as infected, and the physician at the new facility was notified. Interviews with staff and the physician confirmed that the toe was not evaluated as planned and that there was a lack of treatment and monitoring prior to discharge. Facility leadership acknowledged that the resident should have received treatment, monitoring, and physician observation of the wound before discharge.
Unsafe Water Temperatures in Resident and Therapy Areas
Penalty
Summary
The facility failed to ensure that water temperatures in resident areas and the therapy gym were maintained at safe levels, resulting in water temperatures that were significantly above recommended limits. Observations revealed that the water temperature in a shared resident bathroom reached 122 degrees Fahrenheit, despite the boiler being set at 114 degrees Fahrenheit. Maintenance staff were unable to explain the discrepancy between the boiler setting and the actual water temperature. Additionally, documentation showed that the water temperature in the physical therapy gym was recorded at 141.6 degrees Fahrenheit. Staff interviews confirmed that water temperatures were checked weekly, but there was no indication that the excessively high temperatures had been identified or addressed prior to the survey. Three residents with significant care needs, including those with heart disease, diabetes, and cancer, were identified as being at risk due to their dependence on staff for toileting and mobility. Staff interviews indicated that residents had not reported concerns about hot water, and in one case, it was noted that a resident did not use the affected bathroom. However, the presence of excessively hot water in both resident and therapy areas was confirmed through direct measurement and documentation, placing residents at risk for burns.
Failure to Assess and Monitor Resident's Self-Catheterization Practices
Penalty
Summary
The facility failed to assess a resident's ability to self-catheterize in a manner that would prevent urinary tract infections (UTIs). The resident, who had incomplete quadriplegia and a history of multiple UTIs, was able to move their arms but lacked fine motor function. Staff routinely set up catheter supplies for the resident but did not observe or assess the resident's technique or ability to maintain proper hand hygiene during the self-catheterization process. The care plan did not include specific instructions for staff to ensure a clean environment or to verify that the resident performed hand hygiene prior to catheterization. Multiple staff members, including CNAs, RNs, and LPNs, confirmed that they had not observed the resident perform self-catheterization or hand hygiene, and no documentation or assessment was available to demonstrate that the resident was able to perform the procedure safely. The bedside table was observed to have catheter supplies and a urinal, but no hand sanitizer was present. Despite the resident's history of UTIs related to self-catheterization, there was no evidence of education or assessment regarding infection prevention provided to the resident.
Failure to Ensure Accurate Dialysis Communication and Daily Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate communication and documentation between the facility and the dialysis provider for a resident with end stage renal disease (ESRD) who required hemodialysis. Physician orders required staff to complete and send Pre- and Post-Dialysis Assessment and Communication forms with the resident to dialysis on specified days. Review of these forms revealed that some were incomplete, missing vital information such as post-dialysis vitals, comments, and signatures, while others were left entirely blank. Interviews with nursing staff and the Director of Nursing Services confirmed that the forms were not consistently completed or followed up on as required. Additionally, the facility did not obtain and document daily weights for the resident as ordered by the physician. Several days were identified where no weights were recorded, and staff interviews revealed uncertainty about the frequency of weighing the resident and the process for communicating this information. The Director of Nursing Services acknowledged that the resident's weights were not obtained daily as ordered, confirming a failure to follow physician instructions for monitoring the resident's condition.
Failure to Provide Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
A resident with a history of trauma, including suspected financial, sexual, verbal, emotional, and physical abuse, was admitted with diagnoses of psychotic disturbance, mood disturbance, and vascular dementia. The resident's care plan, revised after admission, addressed cognitive impairment and communication strategies but did not include interventions specific to trauma-informed care. Despite documentation from social services and an external physician noting the resident's trauma history and interest in behavioral health support, there was no evidence that trauma-specific needs were assessed or addressed in the care plan. Staff interviews revealed awareness of the resident's PTSD and behavioral responses, such as being jumpy and expressing fear during care activities. However, the Director of Social Services indicated no updates were received regarding the abuse investigation and did not consider the resident appropriate for counseling. Facility leadership confirmed that the care plan should have been individualized to address the resident's trauma history, but this was not done, resulting in a failure to provide trauma-informed care.
Failure to Assess Bed Rail Use Prior to Implementation
Penalty
Summary
A resident admitted with a diagnosis of cancer and on hospice services was observed to have bilateral half bed rails in place. The resident was cognitively intact and required extensive assistance for bed mobility, but stated that the rails were not used to turn. Review of the clinical record revealed there was no assessment conducted regarding the use of bed rails to determine if they posed a risk for entrapment or if they were necessary for the resident’s care. Interviews with staff confirmed that facility policy required an evaluation prior to implementing bed rails, including assessment of whether the rails functioned as a restraint, restricted movement, or posed an entrapment risk. Despite this, staff acknowledged that no such assessment was completed for this resident, even though there were orders for the rails. Maintenance staff were unaware of the rails being in place, and hospice staff confirmed that an assessment was not requested until after the rails had already been applied.
Failure to Provide Recommended Mental Health Services
Penalty
Summary
A resident with diagnoses of post-traumatic stress disorder, agoraphobia, and bipolar disorder was readmitted to the facility and exhibited ongoing depressive symptoms, irritability, and refusal of care, as documented in both the Minimum Data Set (MDS) assessment and physician progress notes. The physician recommended consideration of a referral for a geriatric psychiatric evaluation due to the resident's continued mental health symptoms. However, a review of the clinical record revealed that no referral for mental health evaluation was made, and there was no documentation of any behavioral health services being offered or provided to the resident. Staff interviews confirmed that the resident remained isolated in their room, often with the lights off, and frequently refused personal care. The Certified Nursing Assistant (CNA) described the resident as moody and irritable, with a pattern of refusing care. The Social Services Director was unaware of the physician's recommendation for behavioral health services and acknowledged that no referral had been documented or made. Facility leadership also confirmed that the resident did not receive a behavioral health evaluation, resulting in a failure to provide appropriate mental health services as recommended.
Failure to Appropriately Monitor and Administer Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring and administration of medications for three residents. For one resident with a mental health disorder, a physician's order to decrease the dose of divalproex was not implemented for approximately a month, despite the order being documented in the medical record. This delay was confirmed by both the attending physician and the Director of Nursing Services (DNS). Another resident with Type II diabetes mellitus and neuropathy continued to receive tramadol for pain after a physician's order to discontinue the medication had been issued. Medication administration records showed multiple doses were given after the stop order, which was acknowledged by the DNS. A third resident with heart disease and chronic pain received metoprolol, an anti-hypertensive medication, even when their diastolic blood pressure was below the facility's standing order parameters. The standing orders required staff to hold anti-hypertensive medications if the diastolic blood pressure was below 60, but this was not followed. A certified medication aide (CMA) stated she was unaware of the standing orders and believed medications should only be held if specified on the medication administration record. The DNS confirmed that the medication should not have been administered under these circumstances.
Delayed Physician Notification of Lab Results for UTI
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a resident who was admitted with kidney failure and was being evaluated for a suspected urinary tract infection (UTI). Laboratory samples were collected, and while the initial urinalysis results were communicated to the physician, the final culture results were not reported until six days later. During this period, the resident was not started on antibiotic therapy, and staff did not monitor for complications. Interviews with staff confirmed that there was an expectation to follow up with physicians in a timely manner regarding lab results, and acknowledged that the delay in notification was not appropriate.
Missing Laboratory Results in Resident Record
Penalty
Summary
The facility failed to ensure that laboratory results were included in the clinical record for one resident who was admitted with a diagnosis of stroke. A prescriber ordered blood tests, including thyroid hormone levels, and staff collected and sent the blood samples to the lab. However, the results of the thyroid hormone test were not present in the resident's clinical record. A consultant pharmacist's review noted that the labs had been sent but the results were missing from the record, and staff were unable to provide a reason for the absence of the results or explain why there was no follow-up to ensure the results were obtained and filed.
Failure to Provide Requested and Ordered Menu Items to Residents
Penalty
Summary
The facility failed to ensure that residents' food preferences and menu selections were honored, resulting in two residents not receiving requested or ordered food items. One resident, admitted with anxiety and protein-calorie malnutrition, requested pizza, which was prepared and announced over the intercom, but the resident never received it. The agency CNA responsible was assisting another resident at the time and did not retrieve the pizza, and the dietary manager acknowledged that agency staff may not have been trained on the process for food requests. The resident later stated it was too late to receive the pizza. Another resident, admitted with diabetes and protein-calorie malnutrition, did not receive oatmeal that was listed on their breakfast food ticket. The resident confirmed the omission, and a staff member verified that oatmeal was not present on the tray. The dietary manager explained that oatmeal bowls are placed on food carts, and if they run out, staff are expected to obtain more from the kitchen. The resident stated it was too late to get the oatmeal after finishing breakfast. Facility leadership confirmed that residents should receive the items listed on their food tickets.
Failure to Discontinue Ineffective Prophylactic Antibiotic During UTI
Penalty
Summary
The facility failed to provide appropriate antibiotic stewardship for a resident with incomplete quadriplegia who had a history of urinary tract infections (UTIs) and was on daily prophylactic trimethoprim. Upon admission, the resident was self-catheterizing with staff assistance and continued on the prophylactic antibiotic. A urine culture later identified a UTI caused by an organism resistant to trimethoprim. Despite this, the resident continued to receive trimethoprim daily throughout the month, while also being prescribed a seven-day course of amoxicillin to treat the acute infection. Staff interviews confirmed that the prophylactic antibiotic was not discontinued after resistance was identified, and no documentation was provided to show that the resident's provider approved the continuation of trimethoprim. The Director of Nursing stated the antibiotic was continued to prevent other organisms, but the pharmacist indicated that the prophylactic antibiotic should have been held during the acute UTI unless a physician provided a specific rationale. This lack of action resulted in the continued use of an ineffective antibiotic without proper justification.
Failure to Maintain Cleanliness and Timely Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and functional environment for two residents. One resident, admitted with heart disease, had a portable fan in their room with blades coated in a brown layer of dust. The Maintenance Director acknowledged the fan was dusty and was unsure who was responsible for cleaning the blades. The Housekeeping Manager stated that while the outside of fans were dusted daily, the blades were only cleaned when residents moved out of a room. Another resident, admitted with diabetes and a surgical site infection, experienced multiple issues with broken equipment in their room, including a non-functioning phone and room light. Work orders for these repairs were not completed in a timely manner, and staff were instructed to follow up on repair requests verbally. The resident's family was unable to reach them by phone and had to use 911 dispatch to make contact. An LPN reported needing to use a cell phone light to provide wound care due to the room light being out for three days. The facility administrator acknowledged that work orders were expected to be completed within 24 hours.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
A resident with chronic pain and a Stage 3 pressure ulcer was admitted to the facility and had physician orders for wound care, including dressing changes and wound vac application three times per week. The care plan required staff to observe the wound dressing every shift and document wound observations during dressing changes. On a weekend, the resident did not receive the ordered wound treatment, and the wound vac was not changed as required. Staff interviews revealed that the wound treatment was missed due to an alleged lack of black foam needed for the wound vac, although the unit manager later confirmed that the black foam was in stock. There was no documentation or progress note related to the wound care for the missed treatment, and the physician was not informed about the missed wound care. This failure to follow physician orders placed the resident at risk for worsening of the pressure ulcer.
Failure to Provide Timely Insulin Administration Due to Delayed Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident who was admitted with diagnoses including diabetes and a surgical site infection. Upon admission, the resident had hospital discharge orders for insulin to be administered three times daily with meals. However, documentation showed that the resident did not receive the prescribed lunchtime insulin dose on the day of admission, with the first insulin administration occurring later in the evening. Nursing notes indicated that the pharmacy received the prescription request after noon, and staff interviews confirmed that the resident's medications, including insulin, were not available upon arrival due to issues with the admission process and pharmacy delivery schedules. Further interviews with staff and the facility's pharmacist revealed that the pharmacy received the general medication order request after the deadline for immediate delivery, and an urgent request for insulin was not made until mid-afternoon, resulting in delivery several hours later. The Director of Nursing Services acknowledged that medications should be in place before a resident's arrival. This sequence of events led to a delay in the administration of essential insulin therapy as ordered for the resident.
Failure to Follow Infection Control Standards and Maintain Adequate Supplies
Penalty
Summary
The facility failed to adhere to infection control standards for contact and Enhanced Barrier Precautions for three residents. One resident with sepsis and a Foley catheter was placed on enhanced barrier precautions per physician order and care plan, but staff and family reported inconsistent use of gowns during catheter care. Staff confirmed that gowns were not consistently worn in precaution rooms prior to a certain date, despite expectations for immediate implementation of precautions. Another resident with diarrhea and a UTI was care planned for hand hygiene education and was on antibiotic prophylaxis. Multiple staff and the resident reported ongoing shortages of plastic bags, paper towels, and soap, which hindered the proper removal of soiled linens and appropriate hand hygiene. Staff described having to carry soiled items through hallways or dispose of them in unlined garbage cans, and confirmed that supply shortages were a recurring issue, sometimes related to housekeeping budget constraints and supply management practices. A third resident with a Stage 3 pressure ulcer and a positive wound culture was placed on contact precautions, with signage indicating the need for gowns and gloves. However, staff were observed entering the resident's room and handling personal items without donning the required personal protective equipment (PPE). Some staff stated they believed PPE was only necessary for direct contact, despite the posted precautions and infection preventionist's confirmation that PPE was required when within three feet of the resident or touching personal belongings.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the low temperature dish machine, which placed residents at risk for foodborne illnesses. The dish machine's wash cycle temperatures were required to remain between 120 to 140 degrees Fahrenheit, but logs indicated that the temperatures only reached 120 degrees on specific dates. A work order was submitted by the Dietary Manager due to insufficient hot water, marked as high priority, but was not addressed in a timely manner. The Regional Director of Maintenance marked the issue as completed, but the problem persisted, leading to the use of paper products for meal service when water temperatures were inadequate. Staff interviews revealed that the dish machine's water temperatures were inconsistent, with reports of cold water affecting both dishwashing and resident showers. Despite the inadequate temperatures, management instructed staff to continue using the dish machine, relying on chemical sanitizers. The Regional Dietary Manager acknowledged that the dish machine did not meet the expected wash cycle temperatures, and the Regional Director of Maintenance admitted that the priority work order was not processed promptly, although a new hot water heater was ordered.
Failure to Provide Properly Textured Diets
Penalty
Summary
The facility failed to provide modified textured diets as ordered for two residents, leading to potential risks for medical complications and aspiration. Resident 1, diagnosed with Alzheimer's disease and mood disturbance, required a pureed diet due to swallowing issues. However, on one occasion, a chunk of meat was found in the resident's pureed food, which was not completely processed. Staff 12, the cook, acknowledged the issue, and Staff 10, a CMA, reported the concern to the Dietary Manager. The Dietary Manager, Staff 4, was aware that the non-commercial food processor purchased was inadequate for ensuring a smooth consistency for pureed diets. Resident 2, with a history of stroke and heart disease, also required a pureed diet. The resident was observed with a plate of pureed food that contained small pieces of food, indicating it was not smooth in texture. Staff 4 admitted to not receiving official training related to diet textures, and Staff 9, an SLP, confirmed the food texture did not meet expectations. Staff 12 expressed concerns about the safety of the pureed food texture, and the Regional Dietary Manager, Staff 8, acknowledged the need for additional staff training.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to maintain the highest practicable physical and psychosocial well-being for residents, as evidenced by multiple observations and interviews. On one occasion, a resident was found with a soiled brief and expressed distress due to a lack of staff response to their call light. The staff member nearby was unable to assist immediately due to being behind schedule. Additionally, several other call lights were observed to be activated, indicating a delay in response to resident needs. Resident Council Notes from August to October 2024 highlighted ongoing concerns about long wait times for call lights, particularly on weekends, and staff expressing frustration about short staffing. Multiple residents and witnesses reported similar issues, with some residents experiencing delays of up to an hour for assistance. A family member also noted the difficulty in finding enough staff to assist with two-person tasks. The Director of Nursing Services acknowledged the staffing concerns, confirming the deficiency in meeting resident needs promptly.
Meals Served at Improper Temperatures
Penalty
Summary
Meals were not served at the proper temperature in the facility's kitchen, as observed during a survey. The Food and Drug Administration guidelines require eggs to be served at 135 degrees F or above and milk at 40 degrees F or below. However, during a breakfast test tray conducted with the Administrator and Dietary Manager, the eggs were found to be at 91 degrees F and the milk at 45 degrees F, both below the required temperatures. Residents expressed concerns about late meal service and cold food in the August and September 2024 Resident Council Notes. Multiple residents and a complainant reported that meals were often served late and cold, with one resident stating that meals were cold 75% of the time. Staff members, including dietary aides and a CNA, confirmed that food was consistently cold, lacked seasonings, and was often served late. The Dietary Manager verified that there was a delay between the meal cart being ready and the last resident tray being served.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents in two of the three rooms reviewed, specifically Rooms 117 and 118. Observations revealed that the walls underneath the windows in these rooms were in disrepair, and the baseboard coving was missing. This condition allowed outside air and odors, including cigarette smoke from a nearby outdoor smoking area, to enter the rooms. Witnesses, including a complainant and a resident, confirmed the presence of drafts and smoke odors, with staff resorting to placing towels around the affected areas to mitigate the issue. The facility's administrator and social service director acknowledged the problem, noting that maintenance was aware and that other rooms were similarly affected due to heater replacements.
Neglect of Resident Care Leading to Fall and Hospitalization
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, which placed the resident at risk for unmet care needs. The resident, admitted with a left femur fracture, was to be assisted with toileting every two hours and required appropriate footwear for ambulation or transfers. On the day of the incident, the resident was found on the floor without socks or shoes and with a soiled brief, indicating neglect of care. The resident had not been assisted with toileting for several hours, and the call light was not on. Staff interviews revealed that the resident's bed linens were soaked with urine and feces, and the resident had not received incontinence care all morning. The facility's investigation confirmed neglect of care, as the resident had not been checked on as required. Staff members acknowledged the neglect, noting that the resident's condition was unusual and that the resident typically communicated the need for assistance. The investigation concluded that the resident may have attempted to use the bathroom independently, leading to the fall. The resident was later diagnosed with a urinary tract infection at the hospital, although no injuries from the fall were reported.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for 22 out of 91 days reviewed. This deficiency was identified through interviews and record reviews, including the facility's Direct Care Staff Daily Reports and payroll documents. The specific days without adequate RN coverage were noted in January, February, and March 2024. On June 17, 2024, during an interview, the Administrator and the Director of Nursing Services (DNS) acknowledged the lack of RN coverage on the specified days. The Administrator stated that she expected RN coverage for eight hours each day, but this expectation was not met, placing residents at risk for unmet assessment needs.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent and discuss the risks and benefits of the COVID-19 vaccination with a resident or their representatives before administration. This deficiency involved a resident who was admitted with diagnoses including COVID-19 and heart failure. The resident's immunization record indicated that a COVID-19 booster was administered, but there was no documentation in the medical record showing that the risks and benefits were discussed with the resident or their representatives. A complainant stated that the vaccine was given against the wishes of the resident and their family, who had previously informed the facility of the resident's adverse reactions to past COVID-19 vaccinations. The facility's administrator and DNS confirmed that the vaccine was administered without the necessary education and consent.
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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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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