Evan Terrace Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcminnville, Oregon.
- Location
- 421 Se Evans Street, Mcminnville, Oregon 97128
- CMS Provider Number
- 385225
- Inspections on file
- 30
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Evan Terrace Post Acute during CMS and state inspections, most recent first.
A resident was admitted with an indwelling urinary catheter noted on the admission evaluation, but there was no corresponding catheter order or documented clinical indication in the medical record. An LPN/RCM later confirmed that the resident had been admitted with the catheter in place without any documented reason for its use, constituting a failure to ensure appropriate catheter care and prevention of urinary tract infections.
A resident with a feeding tube received enteral nutrition at a rate much higher than prescribed, as staff left the feeding pump running at 300 ml/hr instead of the ordered 66 ml/hr. The error was discovered when an LPN observed formula bubbling from the resident's tracheostomy site, and staff interviews confirmed the deviation from physician orders.
A resident with dementia and a leg fracture developed multiple facility-acquired pressure ulcers due to the facility's failure to complete baseline and ongoing wound assessments, maintain accurate documentation, and obtain timely wound clinic notes. Staff and leadership were unable to recall or accurately report the resident's condition, resulting in discharge with several unassessed and misdocumented pressure ulcers.
Two residents did not receive medications as ordered by their physicians, including incorrect dosing of levothyroxine for a resident with hypothyroidism and missed insulin doses for a resident with diabetes and neuropathy. Errors included both over-administration and omission of prescribed medications, with staff and administration made aware of the incidents.
A resident with a tracheostomy was transferred to the hospital after improper setup of humidified oxygen was observed. Multiple staff, including agency LPNs and a CMA, reported not receiving tracheostomy training, and the physician assistant noted inconsistent staff knowledge. Facility leadership could not provide documentation of staff training for tracheostomy care.
The facility did not ensure that pharmacist recommendations for medication regimen reviews were acted upon for several residents, including those with dementia, heart conditions, depression, PTSD, and post-surgical needs. Pharmacy recommendations for gradual dose reductions, medication simplification, and laboratory monitoring were repeatedly unaddressed or not communicated to providers, as confirmed by staff interviews and record reviews.
Staff failed to consistently follow infection control protocols for two residents on Enhanced Barrier and droplet precautions, including not wearing required gowns, masks, or eye protection, and not performing hand hygiene. Staff demonstrated a lack of awareness and understanding of the required PPE, and necessary supplies were not always available at the point of care.
Allegations of sexual abuse involving three residents, including one with moderate cognitive impairment and two with no cognitive impairment, were not reported to the State Agency within the required timeframe. Facility management and the Social Services Director were aware of the allegations but did not ensure they were reported or investigated as required.
The facility did not investigate multiple allegations of sexual, physical, and verbal abuse involving several residents, including reports of being hit, sworn at, and inappropriately touched by staff or other residents. Despite staff and management being aware of these allegations, no comprehensive investigations were conducted or documented.
A resident with dementia and behavioral disturbances was administered divalproex sodium, used as an antipsychotic, without documented informed consent. While consent was obtained for other psychotropic medications, there was no signed consent for divalproex sodium, and facility staff confirmed this omission.
A resident with a history of stroke and depression, who was cognitively intact, requested a room change because a roommate's loud television disrupted sleep. The request was reported to the Social Services Director, but no follow-up occurred as staff prioritized discharge planning. The administrator was unaware of the request, and the resident continued to experience noise issues despite using headphones.
A resident with a history of spinal abscess and paralysis had a PRN order for Prochlorperazine that was not reviewed or evaluated by a physician within the required 14-day period. An LPN confirmed that the order continued beyond the allowed timeframe without the necessary assessment or rationale from the prescriber.
A resident with a history of trauma and a diagnosis of schizophrenia, who was cognitively intact, expressed a preference for female caregivers due to discomfort with male staff. Although this preference was known to staff and documented in assessments, it was not included in the resident's care plan.
A resident with diabetes and multiple ulcers did not receive timely wound care due to the facility's failure to obtain and implement updated treatment orders from an outside wound clinic. Staff interviews revealed inconsistent processes for verifying and carrying out new orders, communication challenges with the clinic, and a lack of coordination among providers.
A resident with a feeding tube did not receive appropriate care when staff failed to change the tube feeding bag and tubing daily as ordered, despite documentation indicating it was done. Staff confirmed the missed changes and acknowledged the risks, and the DON verified that daily changes were required.
A resident with severe dementia and behavioral disturbances exhibited frequent aggressive and resistive behaviors, but the care plan was not comprehensively revised to address identified triggers or incorporate detailed staff observations, particularly regarding the calming effect of the resident's spouse and specific behavioral patterns. Staff interviews confirmed the need for a more individualized, resident-centered approach.
A resident with multiple fractures did not receive prescribed physical therapy after returning from a physician visit, as the therapy order was not entered into the health record or communicated to therapy staff. As a result, the resident was not scheduled for the required therapy sessions.
A resident with complex medical needs did not have their feeding tube bag and tubing changed daily as ordered, despite documentation by LPNs indicating the task was completed. Observations and staff interviews confirmed the bag was not changed for several days, resulting in inaccurate medical records.
Two residents experienced falls that were not promptly or thoroughly investigated. In both cases, required witness statements were not collected, and care plans were not updated in a timely manner to address fall prevention. Staff acknowledged delays and incomplete investigations, which did not align with facility policy.
The facility did not make state survey inspection results accessible, as eight residents were unaware of their location and no postings or signage were found throughout the building. The administrator confirmed the absence of these results for both residents and visitors.
The facility did not consistently document registered nurse staffing information on daily reports, with 10 days missing required data during the review period. The Administrator confirmed the incomplete staffing forms.
A facility failed to implement a physician's order for diabetic management for a resident with diabetes and a UTI. The order to check the resident's CBG every morning, at bedtime, and as needed was delayed by seven days, as acknowledged by staff.
A resident with multiple fractures did not receive the prescribed physical therapy five times a week due to staffing issues. The resident missed four therapy sessions, and the deficiency was acknowledged by both the physical therapist and the DNS.
The facility failed to update its Facility Assessment to reflect current ownership and staffing, leading to a deficiency in care for residents with tube feeding needs. The assessment was outdated, listing previous owners and staff, and there was no evidence of training for nursing staff on feeding tube care. Additionally, the facility lacked necessary feeding and NG tubes, as confirmed by the DNS.
The facility failed to ensure nursing staff were trained and competent in managing feeding and NG tubes, essential for residents requiring nutritional supplementation. Despite a meeting where NG tube training was reportedly presented, no documentation was available. The administrator confirmed the absence of training and competency records, and agency nurses received no additional training. The orientation checklist lacked tube feeding and NG tube training, highlighting inadequate training protocols.
The facility inadequately investigated allegations of abuse and neglect for three residents. A resident with dementia reported an intruder, but the investigation lacked thorough documentation and interviews. Another resident was unsafely discharged without follow-up care, and the investigation was incomplete. A third resident's concerns about a roommate and missed medications were not properly investigated, with the FRI submitted late.
The facility did not complete baseline care plans within the required timeframe for two residents, one with a liver transplant and diabetes, and another with dementia, stroke, and COPD. The delays, confirmed by the DNS, were 32 and 21 days post-admission, respectively.
The facility failed to ensure proper discharge planning for two residents, leading to potential health risks. One resident with dementia and wound care needs was discharged without a provider or necessary medical equipment, resulting in an emergency department visit. Another resident with acute respiratory failure was discharged without confirmed home health services, causing a 15-day delay in care.
The facility failed to follow physician orders and notify physicians of omitted medications for three residents, leading to unmet medication and treatment needs. A resident with diabetes and sepsis missed several medications and treatments, while another with a liver transplant and diabetes experienced multiple medication administration failures and delayed wound care. A third resident with cirrhosis and a fractured femur missed doses of lactulose, with delayed provider notification.
A facility failed to provide proper care for a resident with an NG feeding tube, resulting in multiple hospital transfers due to clogged tubes. The resident, with chronic hepatic failure and dysphagia, did not receive necessary nutrition on several occasions. Staff lacked training and competencies for NG tube management, and the facility did not supply necessary NG tube supplies.
Two residents experienced significant medication errors in the facility. A resident with a liver transplant missed doses of critical medications like midodrine and valganciclovir, and had late administrations of prednisone and tacrolimus. Another resident with alcoholic cirrhosis missed doses of lactulose, essential for managing hepatic encephalopathy. These errors were acknowledged by the DNS and Interim DNS.
The facility failed to ensure timely administration of medications for 12 of 15 sampled residents, leading to delays ranging from one to six hours. Staff members cited reasons such as being occupied with other residents and starting shifts late.
The facility failed to ensure sufficient staffing to meet resident care needs, resulting in delayed call light responses, incontinence episodes, and late medication administration. Observations and interviews revealed that residents waited up to two hours for assistance, and staff struggled to complete their duties due to short staffing and high-acuity residents.
The facility failed to ensure residents were free from unnecessary medications. One resident with end-stage renal disease received midodrine despite having a systolic blood pressure greater than 90 on 83 occasions. Another resident with diabetes received insulin lispro even when their CBG was below 120 on seven occasions. Staff acknowledged these discrepancies.
The facility failed to ensure proper labeling of insulin pens, maintain temperature logs for medication storage, and secure medication carts. Open insulin pens were found without open dates, temperature logs were incomplete, and medication carts were left unlocked and unattended, placing residents at risk.
A resident admitted with asthma and acute respiratory failure with hypoxia required continuous oxygen therapy, as indicated in admission orders and observed in daily use. However, the 4/5/24 Admission MDS inaccurately stated that the resident did not require oxygen. This error was confirmed by the Resident Care Manager.
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to a resident within 48 hours of admission. The resident, admitted with diabetes and kidney failure, did not have documentation indicating receipt or review of the baseline care plan. This was confirmed by a Resident Care Manager.
The facility failed to update a care plan for a resident with dementia and hypertension. The care plan required staff to wake the resident at 2:00 AM to void, but CNAs were unaware of this intervention and noted it did not fit the resident's current needs. The DNS confirmed the care plan was outdated.
A resident admitted with multiple pressure ulcers did not receive timely and appropriate wound care. The initial care plan lacked specific interventions, and staff were unaware of the resident's skin issues. Dressings were not changed as ordered, and comprehensive assessments were delayed, leading to worsening conditions.
The facility failed to ensure accurate medical records for a resident, leading to a risk of inaccurate treatment. The resident, who had dementia and hypertension, was documented as receiving pantoprazole at 5:20 AM but was found deceased at 7:15 AM. Police and coroner findings indicated the death occurred around midnight. A former employee admitted to administering the medication the night before and not checking on the resident for the rest of the shift. The administration time was confirmed to be documented incorrectly.
Lack of Documented Clinical Indication for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter had a documented clinical indication for use for one resident. The resident was admitted in August 2025 with diagnoses including schizophrenia, and the admission evaluation dated 8/8/25 indicated the resident had an indwelling urinary catheter in place. However, the admission orders did not include any order for a urinary catheter, and review of the clinical record revealed no documented evidence supporting a clinical indication for the catheter’s use. On 3/16/26 at 9:16 AM, an LPN/Resident Care Manager confirmed that the resident had been admitted with an indwelling urinary catheter and that there was no indication documented for its use. This deficiency was cited under the requirement to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including appropriate catheter care and care to prevent urinary tract infections, and it was noted that this failure placed residents at risk for infection.
Failure to Follow Physician Orders for Feeding Tube Administration
Penalty
Summary
A deficiency occurred when a resident with a feeding tube did not receive care in accordance with physician orders. The resident had a physician order for enteral feeding with Jevity 1.5 at a rate of 66 ml/hr for 18 hours daily, administered via pump. However, staff left the feeding tube running at a rate of approximately 300 ml/hr, significantly exceeding the prescribed rate. This error was discovered when staff observed feeding formula bubbling out of the resident's tracheostomy site. Multiple staff interviews confirmed that the feeding tube was set incorrectly and that the physician's orders were not followed.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for one resident who was at risk for pressure ulcers and had a history of dementia and a right lower leg fracture. Upon admission, the resident had no open skin areas, but over the course of their stay, developed multiple facility-acquired pressure ulcers. The facility did not complete a baseline care plan addressing the resident's skin or risk for pressure ulcers upon admission, and subsequent care plans and assessments contained inaccurate or missing information regarding the presence, staging, and description of the pressure ulcers. There were numerous missing weekly wound assessments for each of the resident's pressure ulcers, and the facility did not document evaluation of the development of these ulcers to determine causative factors or assess the effectiveness of interventions. Additionally, the facility failed to obtain or request the resident's wound clinic notes in a timely manner, and the discharge MDS inaccurately reported the number of pressure ulcers present at discharge. Interviews with multiple staff members revealed that none could recall the resident in question, and facility leadership confirmed the inaccuracies and missing documentation related to the resident's pressure ulcers. These failures resulted in the resident being discharged with multiple unassessed and inaccurately documented pressure ulcers.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding medication administration. For one resident with hypothyroidism and diabetes, a physician order for levothyroxine to be given once daily via feeding tube was incorrectly transcribed as three times daily. As a result, the resident received three doses on one day and two doses on the following day, instead of the prescribed single daily dose. The error was identified in the medical record and confirmed by a physician progress note, but the administrator provided no additional information when informed of the findings. For another resident with a history of above-the-knee amputation and diabetes with neuropathy, multiple doses of prescribed insulin lispro were missed over two consecutive days. The orders included both scheduled and sliding scale insulin doses, but documentation revealed that several doses were not administered as ordered. An LPN discovered the missed doses and reported the issue to the Director of Nursing Services. The administrator was also informed of these findings and did not provide further information.
Failure to Provide Tracheostomy Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective tracheostomy training program for staff caring for a resident with a tracheostomy. The resident, admitted with acute respiratory failure and a tracheostomy, was transferred to the hospital after an incident involving improper setup of humidified oxygen tubing and partially filled humidifier water, as documented by EMS. Staff interviews revealed that multiple staff members, including agency LPNs and a CMA, had not received tracheostomy training from the facility. One LPN reported not feeling qualified to care for a resident with a tracheostomy and relied on a CNA for guidance, while another staff member stated only one nurse was assigned to the resident, with no clear backup if that nurse was unavailable. Further, the physician assistant expressed uncertainty about the staff's competency in tracheostomy care, noting inconsistent answers from staff regarding the resident's care. The administrator and director of nursing services were unable to provide documentation showing that staff had been trained to care for residents with tracheostomies. These findings indicate that the facility did not ensure staff were adequately trained or documented as trained to provide appropriate care for a resident with a tracheostomy.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding medication regimen reviews were considered and acted upon for four out of five sampled residents. According to the facility's policy, a licensed pharmacist is required to review each resident's medication regimen monthly and report any irregularities, which must then be addressed in a timely manner. However, multiple instances were identified where pharmacy recommendations were either not communicated to the physician or not acted upon, resulting in repeated recommendations and lack of documented follow-up. For one resident with dementia and behavioral disturbances, pharmacy recommendations for a gradual dose reduction (GDR) of psychotropic medications were repeatedly made over several months without evidence of action or discussion by the interdisciplinary team. Another resident with chronic heart conditions had pharmacy recommendations for periodic potassium assessments that were not followed up or documented in the clinical record. A third resident with depression and PTSD had multiple pharmacy recommendations to simplify opioid orders and initiate GDRs for psychotropic medications, but there was no physician response or evidence that these recommendations were sent to the physician. Lastly, a resident admitted for surgical aftercare had several pharmacy recommendations regarding pain and PRN medication orders that were not implemented, with facility staff acknowledging that recommendations were not sent to providers during a period when the regular pharmacist was on leave. Interviews with facility staff confirmed that pharmacy recommendations were not consistently communicated to physicians or addressed as required by policy. The lack of timely response and follow-up on pharmacist recommendations placed residents at risk for unnecessary medications and unaddressed medication-related issues.
Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to follow proper infection control protocols for two residents with complex medical needs. One resident with multiple pressure ulcers, including a Stage 4 sacral ulcer, was placed on Enhanced Barrier Precautions (EBP) as indicated by signage outside the room. However, staff were observed entering the room and providing direct care while wearing gloves only, without donning the required gowns. Staff confirmed a lack of understanding regarding the need for gowns and noted the absence of gown supplies near the precaution signage, despite the care plan and CDC guidance requiring both gown and glove use for residents with wounds. Another resident with a tracheostomy, MRSA infection, and pneumonia was on droplet and enhanced standard precautions, as indicated by signage and the care plan. Multiple staff members, including LPNs and agency staff, were observed entering the resident's room without wearing masks or eye protection, and in some cases, without performing hand hygiene. Staff interviews revealed a lack of awareness of the required precautions and inconsistent use of personal protective equipment (PPE), even after being reminded of the protocols. The facility's infection preventionist and director of nursing confirmed that staff were expected to use appropriate PPE and educate visitors, but acknowledged that staff compliance was lacking.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse, including sexual abuse, to the State Agency within the required two-hour timeframe for three residents. One resident with Huntington's Disease and moderate cognitive impairment reported to a witness that a staff member fondled them, but there was no evidence the incident was reported to the facility or the State Agency, and no investigation was conducted. Staff interviews confirmed that management was aware of the allegation but did not initiate an investigation or report the incident as required. Two additional residents, both with no cognitive impairment, reported that an unidentified male caregiver had inappropriately touched their breasts. The Social Services Director was aware of these allegations and reported them to the Administrator for further investigation. However, record review and staff interviews confirmed that these allegations were not reported to the State Agency. The Administrator acknowledged awareness of the allegations but did not fulfill the reporting requirement.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of sexual, physical, and verbal abuse for four of six sampled residents. In one case, a cognitively intact resident reported being hit and sworn at by another resident with severe cognitive impairment, and also reported a prior incident of being slapped. The administrator acknowledged being informed of the incident and speaking to a potential witness but did not document interviews or conduct a full investigation. Staff confirmed witnessing an altercation and reporting it to nursing staff, but no comprehensive investigation was initiated as required. In three additional cases, residents with varying levels of cognitive function reported allegations of sexual abuse by staff or unidentified caregivers. One resident reported to a complainant that a staff member fondled them, but there was no documentation or investigation of the allegation. Two other residents reported that a male caregiver had touched their breasts, and while the social services director was aware and reported the allegations to the administrator, no investigations were completed. Staff interviews confirmed knowledge of the allegations but no evidence of investigations was found in the records.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of divalproex sodium, an anticonvulsant medication used as an antipsychotic, for a resident admitted with dementia with behavioral disturbances and convulsions. Documentation showed that while verbal consent was obtained for other psychotropic medications, divalproex sodium was not included. The resident's admission assessment indicated the use of psychotropic medications to manage agitation and aggressive behaviors, and subsequent interdisciplinary team review confirmed the administration of divalproex sodium. However, a review of the clinical record revealed no signed consent for this medication, and facility staff acknowledged that the required consent was not obtained.
Failure to Honor Resident Room Change Request Due to Noise
Penalty
Summary
A resident admitted with a history of stroke and depression, and assessed as cognitively intact, requested a room change due to the loud volume of a roommate's television, which disrupted sleep. The resident reported the issue to the Social Services Director, but no follow-up was provided, as the staff member was focused on discharge arrangements instead. Observations confirmed the television volume was loud during multiple visits, and the resident resorted to using headphones, which only partially alleviated the problem. The facility administrator was not made aware of the resident's request for a room change.
Failure to Review PRN Psychotropic Medication Orders Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. A resident admitted for surgical aftercare with diagnoses including spinal abscess and lower body paralysis had a PRN order for Prochlorperazine, a medication used to treat nausea and vomiting. Facility records showed that a letter was sent to the prescriber advising that the PRN Prochlorperazine required a direct examination and rationale every 14 days. However, there was no evidence in the resident's medical record that the physician reviewed, assessed, or evaluated the resident within the required 14-day period for the PRN antipsychotic. The LPN Resident Care Manager confirmed that the PRN order continued beyond 14 days without the necessary review and evaluation.
Failure to Address Resident's Gender Preference for Caregivers in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's preference to receive care only from female caregivers. The resident, who was admitted with a diagnosis of schizophrenia and had a history of trauma related to rape and sexual assault, was found to be cognitively intact according to the BIMS assessment. Despite documentation in the social history assessment and direct statements from the resident expressing discomfort with male caregivers and a preference for female staff, the updated care plan did not reflect this preference. Staff interviews confirmed awareness of the resident's preference, but the care plan was not updated accordingly, resulting in the deficiency.
Failure to Implement and Communicate Wound Care Orders for Diabetic Ulcers
Penalty
Summary
The facility failed to obtain and implement treatment orders for a resident with diabetic ulcers, resulting in a lack of timely wound care. The resident, who had a history of diabetes and osteomyelitis, was admitted with multiple arterial and diabetic foot ulcers. Documentation showed that after returning from the wound clinic, new treatment orders were not consistently implemented or reflected in the Treatment Administration Record (TAR). The resident reported a preference for wound care at the clinic and noted that clinic orders were not always followed by the facility. Staff interviews revealed inconsistent processes for verifying and implementing new wound care orders after the resident's visits to the wound clinic. Communication challenges between the facility and the wound clinic were reported, with staff indicating that orders were sometimes requested but not received, and agency staff were not always aware of the procedures. The nurse practitioner did not coordinate communication between the resident's multiple providers, and the regional clinical director expected timely verification and implementation of wound care orders, which did not occur.
Failure to Change Tube Feeding Bag and Tubing as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a feeding tube received appropriate care and services as required. The resident, who had multiple diagnoses including acute respiratory failure, pneumonia, stroke, and a tracheostomy, was admitted with orders for tube feeding using a specific formula and instructions to change the feeding bag and tubing daily at 4:00 PM. Despite these orders and best practice guidelines stating that open system tube feeding containers and tubing should be changed at least every 24 hours, observations revealed that the tube feeding bag in use was dated several days prior and had not been changed as required. Staff interviews confirmed that the tube feeding bag and tubing were not changed on multiple consecutive days, even though documentation indicated otherwise. Staff acknowledged awareness of the missed changes and described the associated risks, including bacterial growth and potential for gastrointestinal issues. The Director of Nursing Services also confirmed that the bag and tubing should have been changed daily according to orders and best practices.
Failure to Revise Dementia Care Plan Based on Resident Behaviors
Penalty
Summary
The facility failed to comprehensively assess and revise the care plan for a resident diagnosed with dementia and behavioral disturbances. The resident, admitted with severe cognitive impairment as indicated by a BIMS score of 6, exhibited frequent behaviors such as kicking, yelling, rejecting care, and threatening or grabbing others on 16 out of 32 days. The care plan was revised to instruct staff to analyze and document triggers and de-escalation strategies, and to engage calmly with the resident before providing care. However, no additional behavior triggers were identified in the care plan despite ongoing behavioral incidents. Staff interviews and observations revealed that the resident's behaviors were influenced by the presence or absence of the spouse, with increased agitation when the spouse left and calmer demeanor during visits. Staff also noted that the resident was less resistive to care when the spouse was present and more likely to hit female caregivers if approached unexpectedly. The Social Services Director, responsible for the dementia care plan, relied primarily on her own observations and staff-initiated feedback, acknowledging that more comprehensive staff input was needed to address the resident's behavioral and dementia-related needs.
Failure to Implement Physician-Ordered Physical Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral heel bone fractures and multiple rib fractures, who was cognitively intact, did not receive physician-ordered physical therapy services. After a physician visit, the resident received a hard copy order from a bone specialist for continued physical therapy two times a week for eight weeks and handed it to a nurse upon returning to the facility. However, the order was not entered into the resident's health record, and no current order for physical therapy was found. Staff confirmed that the therapy order was not communicated or entered, and the resident was not scheduled for the prescribed therapy sessions.
Failure to Accurately Document and Perform Feeding Tube Bag Changes
Penalty
Summary
The facility failed to accurately document and perform feeding tube treatments for a resident with significant medical conditions, including acute respiratory failure, pneumonia, stroke, and tracheostomy status. Physician orders required the resident to receive tube feeding formula with a new bag set up daily at a specified time. However, observation revealed that the tube feeding bag in use was labeled with a date several days prior, and staff confirmed that the bag and tubing had not been changed on multiple consecutive days, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Interviews with staff and review of records confirmed that the feeding tube bag and tubing were not changed as required, and the documentation was inaccurate.
Failure to Timely Investigate and Assess Resident Falls
Penalty
Summary
The facility failed to complete timely assessments and thorough investigations following falls for two residents. For one resident with dementia and a history of falls, staff found the individual on the floor with a hip injury and a wet floor due to incontinence. The fall report lacked additional staff interviews and did not reach a conclusion regarding the incident. Staff involved did not complete the fall report or protocol promptly, and no witness statements were collected. The care plan was later revised, but it did not address the correct fall prevention measures, and staff acknowledged the investigation was incomplete. For another resident with Huntington's Disease and moderate cognitive impairment, a fall occurred but the investigation was not completed until several weeks later, and the fall care plan was not updated. Staff confirmed that the investigation was delayed until the resident was being discharged. In both cases, the facility did not follow its own policy requiring timely and thorough investigations, including collecting witness statements and updating care plans after determining the root cause.
Survey Results Not Accessible to Residents or Visitors
Penalty
Summary
The facility failed to ensure that state survey inspection results were readily accessible to residents and visitors. During a resident council interview, eight residents reported they did not know where to find the survey results within the facility. A subsequent tour of all three facility halls revealed that there were no posted survey results or signage indicating where this information could be located. The facility administrator confirmed that the state survey inspection results were not available for residents or visitors to view.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate nurse staffing information was posted daily, as required. A review of the Direct Care Staff Daily Reports for the month revealed that on 10 out of 31 days, the registered nurse information was not documented. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the staffing forms were incomplete for the identified days. No specific residents or their medical conditions were mentioned in the report.
Failure to Implement Diabetic Management Orders
Penalty
Summary
The facility failed to follow physician orders related to diabetic management for a resident diagnosed with diabetes and a UTI. A physician's progress note dated February 19, 2025, indicated a new order to check the resident's capillary blood glucose (CBG) every morning, at bedtime, and as needed for signs of hypoglycemia or hyperglycemia. However, a subsequent progress note on February 26, 2025, revealed that these orders were not implemented. A review of the diabetic administration record showed that the order was only implemented on February 26, 2025, seven days after the initial order. On March 4, 2025, a staff member acknowledged the delay in implementing the physician's order.
Failure to Provide Prescribed Physical Therapy
Penalty
Summary
The facility failed to provide the required rehabilitation services for a resident who was admitted with multiple fractures. The resident was prescribed physical therapy five times a week for eight weeks, starting from December 24, 2024. However, the therapy service log indicated that the resident only received seven sessions during this period, missing four sessions on specific dates. A concern was reported on December 31, 2024, regarding the missed therapy sessions. Staff 9, the physical therapist, confirmed that due to staffing issues, they were unable to provide the prescribed therapy to the resident. Staff 2, the Director of Nursing Services, acknowledged that the resident did not receive therapy as ordered.
Failure to Update Facility Assessment and Provide Tube Feeding Resources
Penalty
Summary
The facility failed to update its Facility Assessment to reflect current ownership and staffing, which led to a deficiency in the care provided to residents with tube feeding requirements. The assessment still listed the previous owners, Prestige McMinnville, instead of the current owners, PACs, and did not include the current administrator or Director of Nursing Services (DNS). Additionally, the Quality Improvement Director mentioned in the assessment was no longer employed by the facility. The assessment indicated that the facility accepted residents with feeding tubes and that nursing staff would receive training upon hire and in monthly sessions. However, there was no evidence that such training had been conducted. An inspection of the facility's supply closet revealed a lack of necessary feeding or naso-gastric (NG) tubes, and the DNS confirmed that the facility did not have these supplies on hand. Furthermore, the DNS acknowledged that the staff had not been trained to insert feeding or NG tubes, despite the facility's acceptance of residents requiring such care. The administrator admitted that the Facility Assessment had not been updated as required, which contributed to the oversight in training and equipment availability for residents with feeding tube needs.
Lack of Training and Competency in Feeding and NG Tube Management
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent in managing feeding tubes and nasogastric (NG) tubes, which are critical for the care of residents requiring nutritional supplementation. During the survey, it was found that three staff members lacked documented competencies in these areas. The Director of Nursing Services (DNS) mentioned a nurse's meeting held in May or June where NG tube training was supposedly presented, but no documentation could be provided to confirm this. Additionally, the facility's administrator confirmed that no training or competency documentation existed for feeding tubes and NG tubes, and that agency nurses received no additional training upon starting work at the facility. The Human Resources coordinator provided an orientation checklist that did not include tube feeding or NG tube training, further indicating a lack of proper training protocols for these essential skills.
Inadequate Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse and neglect for three residents. For Resident 1, who was admitted with diagnoses including stroke and dementia, an incident occurred where a male allegedly entered the resident's room and attempted to remove the resident's brief. The investigation was incomplete, lacking details such as who conducted it, when it was completed, and whether it was reviewed by the Administrator or DNS. Additionally, interviews were not properly documented, and not all relevant staff were interviewed. The Administrator acknowledged the investigation was not thorough or timely. Resident 5, admitted with diabetes, was discharged without necessary follow-up care, including a primary care physician or home health services, despite having an indwelling urinary catheter and a Wound Vac. The facility's investigation into this unsafe discharge was inadequate, missing witness or staff interviews and lacking evidence of review by the Administrator or DNS. For Resident 13, admitted with a fracture and cirrhosis, there was a failure to investigate concerns about the resident's roommate and missed medication doses. The Facility Reported Incident was incomplete, lacking necessary observations, interviews, and a review of clinical records. The Administrator admitted to not conducting thorough interviews and submitting the report late.
Delayed Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to complete baseline care plans within the required timeframe for two residents, placing them at risk for unmet care needs. Resident 3, who was admitted with diagnoses including liver transplant and diabetes, did not have a baseline care plan completed until 32 days after admission. Similarly, Resident 1, admitted with diagnoses including dementia, stroke, and chronic obstructive pulmonary disease, had their baseline care plan completed 21 days post-admission. These delays were confirmed by Staff 2 (DNS) during an interview and record review.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to potential risks for their health and well-being. Resident 5, who had dementia and multiple wounds requiring a wound vac, was discharged without a primary care provider, home health services, or necessary medical equipment. Despite being informed that the resident's previous provider no longer accepted their insurance, the facility proceeded with the discharge, leaving the resident to seek urgent care or emergency department services for wound vac maintenance. This resulted in the resident visiting the emergency department due to a malfunctioning wound vac and a lack of proper wound care. Similarly, Resident 4, who had been admitted with acute respiratory failure, was discharged without confirmed home health therapy services. Although a referral for home health was sent prior to discharge, the services were not initiated until 15 days post-discharge due to a delay in re-establishing care with the resident's provider. The Social Service Director did not confirm the start date for home health services before the resident's discharge, leading to a significant gap in necessary care and support for the resident after leaving the facility.
Failure to Administer Medications and Notify Physicians
Penalty
Summary
The facility failed to adhere to physician orders and notify the physician of omitted medications for three residents, leading to unmet medication and treatment needs. Resident 2, admitted with diagnoses including diabetes and sepsis, did not receive several medications and treatments as ordered, including amoxicillin, gabapentin, quetiapine fumarate, insulin glargine, and insulin lispro, along with capillary blood glucose checks. These omissions were verified by the Director of Nursing Services (DNS). Resident 3, with a history of liver transplant and diabetes, also experienced multiple medication administration failures. Methocarbamol, simethicone, and chlorhexidine were not administered as ordered, and several medications, including midodrine, methocarbamol, metoprolol, and apixaban, were given late. Additionally, insulin lispro was not administered due to missed capillary blood glucose checks, and wound care orders were not followed. A stool sample for c-diff testing was delayed by six days. Resident 13, diagnosed with cirrhosis of the liver and a fractured femur, missed two doses of lactulose, and the provider was not notified promptly, resulting in a delayed adjustment of the medication dosage.
Inadequate NG Tube Care and Training
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a nasogastric (NG) feeding tube, leading to multiple instances where the resident did not receive necessary nutrition. The resident, who was admitted with chronic hepatic failure and dysphagia, had an NG tube for nutritional support. Despite physician orders for regular verification of tube placement and water flushes, the facility staff repeatedly called 911 due to clogged NG tubes on several occasions, resulting in the resident being transferred to the hospital multiple times. The facility lacked NG tube supplies and did not provide adequate training or competency checks for staff on NG tube management. Interviews with various staff members, including the Director of Nursing Services (DNS), Licensed Practical Nurses (LPNs), and the Infection Preventionist, revealed that the facility did not have the necessary supplies or training protocols in place for managing NG tubes. Staff members admitted to insufficient training and a lack of competencies for handling NG tubes, and the facility did not supply NG tubes for replacement or maintenance. The facility's administrator acknowledged these deficiencies, confirming that the nurses had not been trained on tube feedings and that the facility did not provide the necessary supplies for NG tube care.
Medication Errors in Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident 3, who was admitted with a liver transplant and diabetes, experienced multiple medication errors. These included missed doses of midodrine on two occasions, a missed dose of valganciclovir, and several instances of late administration of prednisone, valganciclovir, and tacrolimus. These medications are critical for preventing organ rejection and managing the resident's health post-transplant. The errors were acknowledged by the Director of Nursing Services (DNS) on November 21, 2024. Resident 13, admitted with alcoholic cirrhosis of the liver, also experienced significant medication errors. The resident's medication regimen included lactulose, essential for managing hepatic encephalopathy by removing toxins from the bloodstream. However, doses of lactulose were not administered on two occasions, which was acknowledged by the Interim DNS on November 19, 2024. The failure to administer these medications as ordered placed the resident at risk for severe health complications.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure physician orders were followed for 12 of 15 sampled residents reviewed for medications. This failure placed residents at risk for reduced medication efficacy and adverse medication side effects. For instance, Resident 94, who was admitted with diagnoses including cellulitis and a pressure ulcer, did not receive her medications on time on multiple occasions. Staff members acknowledged the delays, citing reasons such as being occupied with other residents and starting their shifts late. Another instance involved Resident 144, who was admitted with heart failure. The resident did not receive their prescribed medications, Eliquis and metoprolol, on the evening of their admission and did not receive the first dose until the following morning. Staff members confirmed the delay and acknowledged the oversight. Additionally, multiple residents, including Residents 32, 28, 1, 10, 33, 4, 11, 14, 145, and 30, experienced significant delays in receiving their medications. These delays ranged from one hour to six hours late, affecting various medications such as insulin, carvedilol, and gabapentin. Staff members confirmed these delays during medication administration audits and acknowledged the issues when made aware of them.
Insufficient Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet resident care needs, as evidenced by multiple observations, interviews, and record reviews. On 4/18/24, the facility provided lists of residents requiring various levels of assistance, including eating, transfers, dressing, bathing, toileting, and incontinence care. Resident Council Notes from January and February 2024 highlighted concerns about delayed call light responses, with specific instances of call lights not being answered during shift changes and residents being left in soiled briefs. Observations on 4/17/24 revealed call light response times ranging from 23 to 26 minutes, and resident interviews indicated wait times of up to two hours, leading to episodes of incontinence and delayed medication administration. Staff interviews corroborated these findings, with multiple staff members reporting being unable to complete their duties due to short staffing. A CMA stated she was the only one passing medications for the entire facility, often finishing morning medications just before noon. CNAs and LPNs reported difficulties in taking breaks, completing assigned duties, and managing high-acuity residents. One LPN was observed to have ten residents with late medications due to being pulled in multiple directions. Another LPN confirmed that medications were often given late at night due to the high volume of tasks, including new admissions and assessments. The deficiency was further supported by specific resident and staff testimonies. Residents reported lengthy call light response times, leading to incontinence and delayed care. Staff members described the challenges of managing high-demand residents and completing their tasks on time. The overall findings indicate that the facility's staffing levels were insufficient to meet the care needs of the residents, resulting in delayed and unmet care needs, including incontinence care and timely medication administration.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications for two residents. Resident 6, who was admitted with end-stage renal disease, had a physician order to receive midodrine TID PRN if the systolic blood pressure was less than 90. However, from mid-March to mid-April, there were 83 instances where midodrine was administered despite the systolic blood pressure being greater than 90. Staff 2 acknowledged this discrepancy. Similarly, Resident 4, admitted with diabetes, had a physician order to receive insulin lispro 13 units before meals, to be held if the CBG was less than 120. Despite this, there were seven instances from mid-March to mid-April where insulin was administered even though the CBG was below 120. Staff 2 also acknowledged this error.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of biologicals, proper storage temperatures were logged and maintained, and medication carts were properly secured. Specifically, two open insulin pens were found in the 300-hall treatment cart and one open insulin pen in the 200-hall treatment cart, all without open dates. Staff acknowledged the insulin pens were open and not labeled with open dates. Additionally, the controlled medication refrigerator contained a thermometer and medications but lacked a temperature log. The temperature logs for March and April 2024 indicated multiple instances where temperatures were not logged twice daily, and on several occasions, the temperatures were outside the required range of 36 F to 46 F. Staff were unsure who was responsible for recording the temperatures, and the Director of Nursing Services acknowledged the discrepancies in temperature logging and out-of-range temperatures. Furthermore, on two separate occasions, a treatment cart containing antibiotics and blood pressure medications was observed to be unlocked and unattended in the long-term care nursing unit. Staff confirmed the cart was unattended and unlocked and subsequently locked it. These lapses in medication management placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to accurately code MDS assessments for a resident who required oxygen therapy. Resident 295, admitted with diagnoses including asthma and acute respiratory failure with hypoxia, had admission orders indicating the need for continuous oxygen therapy. Despite this, the resident's 4/5/24 Admission MDS inaccurately indicated that the resident did not require oxygen. This discrepancy was confirmed through interviews and record reviews, including observations of the resident using oxygen and statements from the resident and staff. The Resident Care Manager acknowledged the coding error on 4/18/24.
Failure to Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission. This deficiency was identified for one resident who was admitted in December 2023 with diagnoses including diabetes and kidney failure. The resident's care plan dated December 26, 2023, did not indicate that the baseline care plan was received or reviewed. Additionally, the resident's Medication Administration Record (MAR) for December 2023 revealed no documentation that the baseline care plan was provided or reviewed. This was confirmed by a Resident Care Manager during an interview on April 19, 2024.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of residents. Resident 246, who was admitted in June 2023 with diagnoses including dementia and hypertension, had a care plan dated January 29, 2024, indicating that staff were to wake the resident at 2:00 AM every morning to void. However, on April 17, 2024, three CNAs stated they were not aware of this intervention and noted that the resident was often up and down at night, suggesting the intervention did not fit the resident's current needs. On April 19, 2024, the Director of Nursing Services confirmed that the intervention was not current and the care plan needed updating.
Failure to Ensure Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure pressure ulcers were assessed, treated, and care planned appropriately for a resident admitted with multiple skin impairments, including pressure ulcers on both heels and a Stage 2 pressure ulcer on the right elbow. The initial care plan did not identify the resident's pressure ulcers or include specific interventions for them. Despite receiving orders for wound care, including daily dressing changes, there was no indication that these treatments were implemented from the time of admission until several days later. The resident reported that dressings were not changed for a couple of nights, and staff were unsure of the resident's skin issues or the required interventions. Upon assessment by the wound care nurse practitioner, it was found that the dressings on the resident's heel wounds were dated several days prior, and there was no comprehensive assessment, measurements, or treatments implemented until a week after admission. The wound care nurse practitioner identified multiple unstageable pressure ulcers and a Stage 3 pressure ulcer on the left heel. The Director of Nursing Services acknowledged the lack of timely and appropriate wound care for the resident, confirming the deficiency in pressure ulcer management and care planning.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for one resident, leading to a risk of inaccurate treatment. Resident 246, who had dementia and hypertension, was documented as receiving pantoprazole at 5:20 AM. However, the resident was found deceased at 7:15 AM, with police and coroner findings indicating the death occurred much earlier, around midnight. A former employee admitted to administering the medication the night before and not checking on the resident for the rest of the shift. The administration time was confirmed to be documented incorrectly by both the former employee and the facility administrator.
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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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