Creswell Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Creswell, Oregon.
- Location
- 735 South 2nd Street, Creswell, Oregon 97426
- CMS Provider Number
- 385182
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Creswell Post Acute during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbance was found with a bruise to the left eye, and staff could not determine the cause of the injury. Although a CNA reported the bruise to an LPN, the incident was not reported to the State Survey Agency in a timely manner, resulting in non-compliance with reporting requirements.
A resident was discharged without a documented discharge plan, as required. Review of the clinical record showed the discharge plan was overdue, and neither the care plan nor care conference notes addressed the resident's discharge preferences. Staff interviews confirmed the discharge plan was not completed and revealed a lack of familiarity with the discharge planning procedure.
Two residents with complex medical needs, including a fractured femur, osteoarthritis, pressure ulcer, and chronic kidney disease, did not have their required MDS assessments completed on time. Staff confirmed that these assessments were overdue and acknowledged the delay.
A resident with dementia was involved in incidents of agitation and physical aggression, but the care plan was not updated in a timely manner to include interventions to prevent further occurrences. The care plan revision was delayed despite the identification of necessary interventions after the initial incident, as confirmed by the DON.
Two residents with chronic medical conditions and intact cognition experienced prolonged call light wait times of 40 and 47 minutes. Staff members reported being occupied with other duties or lacking communication devices, and the DON confirmed that these wait times were too long.
The facility failed to provide complete discharge summaries for three residents, omitting essential information from their most recent assessments. A resident with diabetes, another with heart failure, and a third with dementia had discharge summaries lacking details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. This was acknowledged by the DNS during an interview.
The facility failed to properly store and label medications and biologicals, as observed during audits of a treatment cart and a medication refrigerator. An open vial of Insulin Glargine was found to be over 28 days old, and an undated tuberculin vial and expired Spikevax vaccines were discovered. Staff confirmed these findings and acknowledged the need for proper labeling and disposal.
The facility failed to follow physician orders and provide timely care, resulting in deficiencies. A resident had bed rails removed without notification, another experienced delayed bowel care and inconsistent pain medication administration, and a resident consumed excess alcohol during an outing. Medication administration delays were common, with staff citing high acuity and workload as reasons. Residents expressed dissatisfaction with these delays.
A facility failed to obtain consent for an influenza vaccination for a cognitively intact resident with diabetes. The resident received the vaccine, but a review of their medical record showed no signed consent. The DNS confirmed the absence of consent, acknowledging it should have been obtained before vaccination.
The facility failed to notify emergency contacts and a physician in two cases. A resident hospitalized for abdominal issues had no emergency contacts informed, despite being cognitively intact. Another resident, post-spinal surgery, developed a lump on the back, but the physician was not notified, although the family was informed. Staff later acknowledged these communication lapses.
A resident, who was cognitively intact and had diabetes, reported that her/his cell phone was stolen, leading to a $300 replacement cost. Despite informing social services, no grievance form was completed. The staff acknowledged the need for a grievance form and investigation.
A facility failed to provide a bed hold policy to a resident during hospitalization, which is necessary to inform them of their rights to return. The resident, admitted in 2018 with delayed stomach and intestine emptying, was hospitalized multiple times without receiving the policy. Social Services staff stated that they provided the policy if present, but nursing staff were responsible after hours or on weekends. It was confirmed that the resident did not receive the policy during their hospitalizations.
A resident admitted with paralysis after spinal surgery did not have a baseline care plan that included necessary spinal precautions. The care plan was updated over a week later to include log-rolling and spinal precautions, but the resident reported staff did not follow these directions. Staff interviews revealed a lack of effective communication and documentation of the necessary precautions.
A resident with third-degree burns was discharged from an LTC facility without proper wound care training or home health support, leading to hospital readmission for infected wounds. The facility failed to ensure the resident or their roommate received necessary wound care instructions, resulting in a lack of adequate post-discharge care.
A resident with severe cognitive deficits did not receive necessary assistance with ADLs, including regular showers and nail care, as required. Observations showed the resident had dirty hair and fingernails, and documentation lacked evidence of refusal for missed bathing dates. Staff confirmed the resident should have received showers twice a week.
The facility failed to assist two residents in obtaining prescription glasses, risking impaired vision. One resident, admitted with bowel and stomach dysfunction, did not receive glasses despite a new prescription. Social Services staff were unaware of the prescription. Another resident with diabetes experienced a delay in receiving glasses after an ophthalmologist visit, with no staff follow-up recorded. Staff acknowledged the issue but had not completed the order through insurance.
A resident with a right finger contracture did not receive a necessary splint, despite assessments and referrals indicating its need. The care plan did not include the splint, and staff were unaware or had not seen the splint applied. This oversight was identified as a deficiency in the facility's care.
A facility failed to maintain a medication error rate below five percent, with two errors in 39 opportunities. A resident with chronic conditions did not receive Creon at the prescribed time, and staff failed to ensure mouth rinsing after Advair Diskus use, as per physician orders.
A resident admitted with diabetes, who was cognitively intact, signed an arbitration agreement but later did not recall doing so, citing heavy medication and lack of follow-up. The Social Service Director, responsible for explaining and managing arbitration agreements, confirmed that she did not follow up with residents after they signed, considering it a one-time task. This led to a deficiency in ensuring the resident's understanding of the agreement.
A resident with post-surgical paraplegia, who was cognitively intact, experienced a dignity-related deficiency when a CNA initially refused to change wet sheets, causing the resident frustration and fear. The CNA eventually changed the sheets after initially insisting they were not wet. The DNS confirmed that staff should honor such requests.
A resident's right to privacy was violated when a staff member at an LTC facility opened their mail without permission. The resident, who was cognitively intact and had diabetes, reported the incident, which involved a package containing supplements. Staff acknowledged the error, emphasizing that mail should be delivered unopened, and staff should only be present when residents open suspected medication packages.
A resident admitted with paralysis developed a pressure ulcer due to inconsistent implementation of a care plan aimed at preventing such injuries. Despite being at risk, the resident was not consistently turned every two hours, and education on positioning was not regularly provided. Staff acknowledged challenges in adhering to care standards, contributing to the development of a deep tissue injury.
A resident with moderate cognitive impairment and a history of alcohol use consumed more beer than the physician-ordered limit during an outing. Two staff members failed to supervise the resident adequately, allowing the resident to drink additional beers provided by a non-staff member. The resident returned to the facility with altered vital signs, and the staff did not report the excess alcohol consumption to the nurse.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report in a timely manner an allegation of injury of unknown source for one resident with behavioral disturbance and dementia. The resident was found with a bruise to the left eye, and staff were unable to determine how the injury occurred, nor could the resident explain the incident. A CNA observed the bruise and reported it to an LPN, but the incident was not reported to the State Survey Agency as required. The Director of Nursing confirmed that the incident met the criteria for non-compliance due to the delay in reporting.
Failure to Provide Discharge Plan for Resident
Penalty
Summary
The facility failed to provide a discharge plan for one of three residents reviewed for discharge planning. Review of the clinical record for this resident showed no evidence of a discharge plan, and a notification in the record indicated the discharge plan was overdue by 16 days. The resident's care plan did not address discharge preferences, and care conference notes also lacked documentation of a discharge plan. During interviews, the Social Services Coordinator acknowledged that the discharge plan should have been completed, and the Director of Nursing Services stated she was not familiar with the discharge planning procedure, noting that it was the responsibility of Social Services to complete the discharge plan.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely Minimum Data Set (MDS) assessments for two residents. One resident, admitted with a fractured femur and osteoarthritis, had an admission MDS assessment that was still in progress and overdue by 15 days. Another resident, admitted with a pressure ulcer and chronic kidney disease, had an annual MDS assessment that was also in progress and overdue by 15 days. Staff interviews confirmed that the MDS Coordinator was behind on assessments and that MDS assessments are expected to be completed in a timely manner.
Failure to Timely Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to update the care plan for a resident with dementia following a reported incident of agitation and subsequent physical aggression. The resident was admitted with a diagnosis of dementia and was involved in an incident where the care plan was supposed to be revised to include an intervention to keep the resident further than an arm's length away from others when agitated. Although this intervention was identified after a facility reported incident, the care plan was not updated until after a second incident of physical aggression occurred. The Director of Nursing Services acknowledged that the care plan should have been updated within five days of the initial incident but was not revised in a timely manner.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of two residents during random observations. One resident, admitted with chronic kidney disease and epilepsy and assessed as cognitively intact, experienced a call light wait time of 47 minutes, as observed on the call light monitor. The resident confirmed that call light wait times were sometimes long, and a CNA reported being occupied with another resident's care during the delay. The CNA also noted that staff no longer had access to communication devices previously used to coordinate care. The Director of Nursing Services acknowledged that the wait time was too long. Another resident, admitted with anxiety and chronic pain and also cognitively intact, had a call light wait time of 40 minutes. The CNA assigned to this resident was working in the dining room during the delay, and the Director of Nursing Services confirmed this wait time was also excessive.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete comprehensive discharge summaries for three residents, which included a final summary of their status at the time of discharge. This deficiency was identified during interviews and record reviews. Resident 2, admitted in July 2024 with diabetes, had a discharge summary dated August 28, 2024, that did not include all necessary items consistent with their most recent comprehensive assessment. Missing information included details on functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcers, and pain. Similarly, Resident 4, admitted in July 2024 with heart failure, and Resident 5, admitted in June 2018 with dementia, also had incomplete discharge summaries. The discharge summaries for these residents, dated September 4, 2024, and August 26, 2024, respectively, lacked comprehensive details from their most recent assessments. These omissions were acknowledged by Staff 1 (DNS) during an interview on October 9, 2024, confirming that the discharge summaries did not provide a complete summary of the residents' final status upon discharge.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, which was identified during an audit of the South Hall treatment cart and the medication and biologicals refrigerator. An open vial of Insulin Glargine was found in the treatment cart with a date indicating it was over 28 days old, which should have been discarded. This was confirmed by a registered nurse (RN) during the audit. Additionally, an audit of the medication and biologicals refrigerator revealed an open and undated multi-dose vial of tuberculin solution and multiple closed vials of Spikevax (COVID-19 vaccine) with an expired date. A licensed practical nurse (LPN) verified the absence of an open date on the tuberculin vial and disposed of it in the sharps container. The expired Spikevax vials were acknowledged, with the facility awaiting a pharmacy exchange for viable vaccines. The RNCM stated that the expectation was for all medications to have an open date and for expired medications to be discarded appropriately.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents, leading to multiple deficiencies. One resident, admitted with cancer, had their bed rails removed without family notification, which were not transferred to a new bed. Another resident, admitted with paralysis, experienced delayed bowel care and inconsistent administration of pain medication, with staff failing to document or provide additional interventions when initial treatments were ineffective. A resident with alcohol use issues consumed more alcohol than permitted during an outing, as staff failed to supervise adequately and did not report the excess consumption to the facility upon return. Another resident received the wrong medication due to a discrepancy in the Medication Administration Record and Narcotics Log, although no adverse effects were reported. Additionally, several residents experienced delays in receiving their scheduled medications, with staff citing high resident acuity and workload as reasons for the delays. The report highlights systemic issues in medication administration and care delivery, with multiple instances of late or missed medications for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and epilepsy. Staff acknowledged the challenges in meeting scheduled medication times, and residents expressed dissatisfaction with the delays, indicating a need for improved processes and staffing to ensure timely and accurate care.
Failure to Obtain Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain consent for an influenza vaccination for one resident, who was part of a sample of five residents reviewed for immunizations. The resident, admitted in October 2023 with a diagnosis of diabetes, was cognitively intact as indicated by a quarterly MDS assessment. A review of the resident's immunization record showed that the influenza vaccine was administered in December 2023. However, upon reviewing the medical record, there was no evidence of a signed consent for the vaccine. The Director of Nursing Services confirmed the absence of the signed consent and acknowledged that consent should have been obtained prior to administering the vaccine.
Failure to Notify Emergency Contacts and Physician
Penalty
Summary
The facility failed to notify a resident's emergency contacts and physician in two separate incidents, leading to deficiencies in communication and care. Resident 18, who was admitted to the facility in 2010 with a diagnosis of delayed stomach and bowel emptying, was transported to the hospital for abdominal pain, nausea, vomiting, and uncontrolled diarrhea. Despite being cognitively intact, as indicated by a quarterly MDS, Resident 18's emergency contacts were not informed of the hospitalization, as confirmed by both the resident and Staff 3 (RNCM). In another incident, Resident 47, who was admitted in July 2024 with paralysis following spinal surgery, experienced a change in condition when a small lump was identified above the surgical incision after reporting a popping sensation in the back. Although the family was informed and planned to contact the spinal surgeon, the facility staff did not notify the resident's physician about the lump. This oversight was acknowledged by Staff 2 (DNS) and Staff 3 (RNCM) during an assessment of the resident's spine.
Failure to Initiate Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance process for a resident who was cognitively intact and had been admitted with diagnoses including diabetes. The resident reported that her/his cell phone was stolen a couple of months ago, resulting in a personal expense of $300 to replace it. Despite informing the facility's social services staff about the incident, no grievance form was filled out by either the resident or the staff member. The staff member acknowledged that this situation should have been treated as a grievance and required a formal grievance form and investigation.
Failure to Provide Bed Hold Policy During Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received a bed hold policy during hospitalization, which is a requirement to inform residents of their rights to return to the facility. This deficiency was identified for one of the two sampled residents reviewed for hospitalization. Resident 18, who was admitted to the facility in 2018 with a diagnosis of delayed emptying of the stomach and intestines, was hospitalized on multiple occasions between October 2023 and August 2024. However, the progress notes did not indicate that Resident 18 or their emergency contacts were provided with a bed hold policy during these hospitalizations. On August 29, 2024, Staff 4 from Social Services stated that if she was present when a resident was discharged to the hospital, she ensured the resident or their representative received a bed hold policy. However, if the discharge occurred after hours or on weekends, the nursing staff was responsible for providing the policy. It was confirmed that Resident 18 was not provided with bed hold policies at the time of their hospitalizations.
Failure to Implement Baseline Care Plan for Spinal Precautions
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a diagnosis of paralysis after spinal surgery. The baseline care plan, initiated several days after admission, did not include necessary precautions such as log-rolling and spinal precautions to prevent twisting of the spine. These precautions were only added to the care plan over a week later, following a therapy document that indicated the need for two staff to assist with bed mobility and ensure no leg movement. Despite the care plan update, the resident reported that staff did not follow the therapy directions for turning. Interviews with staff revealed that the necessary spinal precautions were not communicated effectively, as they were not included in the initial baseline care plan. Staff members acknowledged that the information was typically provided verbally by the nurse upon admission and added to the care plan within 24 hours, but in this case, the precautions were not documented until much later.
Failure in Safe Discharge Planning for Resident with Burn Wounds
Penalty
Summary
The facility failed to ensure safe discharge planning services for a resident who was admitted with third-degree burns to the left chest, abdomen, and thigh. Upon discharge, the resident was sent home with orders for home health and daily wound care. However, the home health services did not visit the resident before they were readmitted to the hospital due to concerns of wound infection and inability to self-care. The resident's burn wounds were found to be infected, requiring intravenous antibiotics. Interviews with facility staff revealed that although home health was ordered, they did not have time to see the resident before the hospital readmission. Additionally, there was no evidence of wound care training provided to the resident or their roommate, who was supposed to assist with wound care. The resident reported being discharged by mistake, as they were unable to perform wound care independently and had no family or friends to assist. The facility did not discuss or train the resident on wound care prior to discharge.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with severe cognitive deficits, placing the resident at risk for unmet needs. The resident, admitted with a diagnosis of diabetes, was observed with dirty hair and jagged fingernails, indicating a lack of proper hygiene care. Documentation revealed that the resident did not receive scheduled showers or bathing on multiple occasions, with no evidence of refusal documented for several missed dates. Staff acknowledged the resident should have received showers twice a week and confirmed the absence of documentation for refusals on specific dates.
Failure to Assist Residents in Obtaining Prescription Glasses
Penalty
Summary
The facility failed to assist two residents in obtaining prescription glasses, which placed them at risk for impaired vision. Resident 18, who was admitted in October 2018 with bowel and stomach dysfunction, reported blurred distant vision during an eye exam in June 2024 and received a new prescription. Despite being cognitively intact, Resident 18 stated in August 2024 that they had not received the new glasses. Staff members from Social Services were unaware of the new prescription and did not have the after-visit summary, indicating a lack of follow-up on the resident's vision care needs. Similarly, Resident 3, admitted in March 2023 with diabetes, experienced a delay in receiving prescription glasses. Progress notes from July 2024 indicated that Resident 3 inquired about the status of their glasses, but there was no evidence of staff follow-up in the clinical record. In August 2024, Resident 3 reported seeing an ophthalmologist six weeks prior and was told the glasses would take about three weeks to arrive, yet they had not been received. Staff acknowledged awareness of the appointment and provided an invoice for the glasses dated June 2024, but the order had not been completed through the insurance provider.
Failure to Provide Necessary Splint for Resident
Penalty
Summary
The facility failed to provide a necessary splint for a resident with a right finger contracture, which was identified as a deficiency. The resident, admitted in March 2010 with a diagnosis of cancer, had an occupational therapy treatment encounter on May 9, 2024, where measurements for a right finger splint were obtained. However, the care plan last revised on July 5, 2024, did not include the requirement for a right finger splint. A physician appointment on July 24, 2024, noted the resident's right finger swelling and redness, and a referral for a finger splint was made. Despite these assessments and referrals, the resident was observed without a finger splint on August 27, 2024. Interviews with staff revealed a lack of awareness and documentation regarding the need for the splint. Staff 4, responsible for making appointments for referrals, was unaware of the need for a hand therapist or splint. Staff 15 confirmed that a splint was ordered, but it was not included in the care plan. Other staff members, including CNAs and a CMA, reported never seeing or applying a splint to the resident's finger. The RNCM acknowledged that the splint was not on the care plan, despite having helped order one.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 5.13 percent error rate. This was based on observations, interviews, and record reviews. Specifically, there were two errors in 39 medication administration opportunities. One of the errors involved a resident with chronic pancreatitis and chronic obstructive pulmonary disease, who was admitted in August 2024. The resident's physician orders included Creon to be administered three times a day with meals and Advair Diskus to be administered twice a day. On August 28, 2024, a staff member administered the resident's medications after breakfast but failed to have the resident rinse and spit after using the Advair Diskus, as required. Additionally, the Creon was not administered at the provider-ordered time of 8:00 AM.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident understood an arbitration agreement, which was a deficiency identified during a survey. Resident 47, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact according to the admission MDS, signed an arbitration agreement shortly after admission. However, the resident later stated that they did not recall signing the agreement, attributing this to being heavily medicated at the time and not receiving any follow-up regarding the agreement. The Social Service Director, responsible for admission paperwork, including arbitration agreements, confirmed that she explained the agreement and its optional nature but did not follow up with residents after they signed, considering it a one-time task. This lack of follow-up contributed to the resident's lack of understanding of the arbitration agreement.
Resident Dignity and Self-Determination Compromised
Penalty
Summary
A deficiency was identified involving the dignity and self-determination of a resident diagnosed with post-surgical procedure paraplegia, who was admitted to the facility in July 2024. The resident, who was cognitively intact, reported feeling frustrated and afraid due to interactions with a CNA regarding the changing of bed sheets. On one occasion, the resident requested the CNA to change sheets that were wet from sweat, but the CNA initially insisted the sheets were not wet and did not need changing. The resident felt compelled to argue to receive care. Eventually, the CNA left the room, returned with another CNA, and the sheets were changed. The DNS confirmed that staff should honor such requests from residents, and the resident reported feeling that it took too long for staff to return and provide the requested care.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to respect the privacy and confidentiality of a resident's personal mail. Resident 12, who was admitted to the facility with a diagnosis of diabetes and was cognitively intact, reported that a staff member opened a package addressed to them without permission. The incident occurred when a staff member, identified as Staff 5, opened the package after hearing a sound that suggested it contained supplements or medication. This action was acknowledged by Staff 5 as a violation of the resident's rights. Further interviews revealed that Staff 14, the Activity Director, confirmed the accidental opening of the package and emphasized that all mail addressed to residents should be delivered unopened. Staff 3, an RNCM, was unaware of the incident but stated that staff should never open a resident's mail, even if it is suspected to contain medication. Instead, staff could be present when the resident opens their mail. The failure to deliver the mail unopened compromised the resident's right to privacy and confidentiality.
Failure to Prevent Pressure Ulcers in Resident with Paralysis
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident who was admitted with paralysis after spinal surgery. Upon admission, the resident did not have any pressure ulcers, and a care plan was initiated to address the risk of pressure ulcer development. However, the care plan's interventions, which included educating the resident and family on positioning requirements, were not consistently implemented. Progress notes from late July to early August indicate that the resident was assisted with turning and bed mobility, but the frequency of these actions was not documented. Additionally, there were several instances where no education was provided to the resident or family, despite the resident's reluctance to move due to incision pain. By early August, the resident developed a deep tissue injury on the sacral area, which was identified as a skin impairment with a moisture component. Interviews with staff and the resident's spouse revealed that the resident was not consistently turned every two hours, as required by standard care practices. Staff members acknowledged the challenges in adhering to the turning schedule due to time constraints and the resident's preference to remain on their back with the head of the bed elevated, which increased pressure on the coccyx region. The lack of consistent turning and education contributed to the development of the pressure ulcer.
Inadequate Supervision During Resident Outing Involving Alcohol
Penalty
Summary
The facility failed to provide adequate supervision during an outing involving alcohol for a resident with a history of alcohol use and moderate cognitive impairment. The resident was allowed to consume more alcohol than the physician-ordered limit of 12 ounces of beer. During the outing, two staff members, a Staffing Coordinator and an HR staff, were responsible for supervising the resident. However, they were unaware that the resident consumed additional beers beyond what was initially provided. The resident's condition changed upon returning to the facility, showing signs of fatigue, decreased responsiveness, and abnormal vital signs, prompting a call to EMTs. The investigation revealed that the resident consumed three and a half 12-ounce beers, exceeding the physician's order. The staff members involved did not inform the facility's nurse about the actual amount of alcohol consumed by the resident. Additionally, the staff allowed the resident to be unsupervised on the riverbank with a non-staff member, who provided the resident with more beer. This lack of supervision and communication led to a failure in ensuring the resident's safety during the outing, as evidenced by the resident's altered condition upon return.
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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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