Fernhill Rehabilitation And Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5737 Ne 37th Avenue, Portland, Oregon 97211
- CMS Provider Number
- 385237
- Inspections on file
- 22
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Fernhill Rehabilitation And Care during CMS and state inspections, most recent first.
The facility did not provide written or verbal responses to concerns raised by resident council members during two meetings, despite policy requiring tracking and resolution of such issues. Concerns included care, staff performance, cleanliness, and food services. Staff and residents confirmed that concerns were documented and shared, but no feedback was given to the council.
A resident with depression and anxiety, who was cognitively intact, reported missing personal property and submitted multiple grievances. The facility did not document resolutions, obtain signatures, or notify the resident of investigation outcomes, as required by policy. Both the Social Services Director and Administrator confirmed the grievance process was not properly followed.
Surveyors found that kitchen food prep areas were not kept clean or sanitary, with hundreds of small bugs present on surfaces and in traps, missing and uncleanable caulking, and a persistent rancid odor under the food prep sink. Staff confirmed ongoing issues with bugs swarming, migrating to food prep areas, and biting staff, as well as a longstanding foul smell that had not been resolved.
A resident who was cognitively intact and used a power wheelchair was discharged from the facility, but staff failed to return the resident's wheelchair. Instead, the wheelchair was stored for several months and then disposed of without any attempt to deliver it back to the resident.
Surveyors found that the facility did not provide a homelike environment in two of three hallways reviewed. A resident's personal fan was observed with a thick layer of dust and grime, and the resident reported waiting for staff to clean it. Multiple rooms had walls with scrapes, holes, and uncleanable surfaces, as well as dust build-up, sticky furniture, and other cleanliness issues. Residents and staff confirmed the need for cleaning and repairs.
A resident with a history of stroke and significant dental issues, including missing upper teeth and broken tooth fragments, was observed to have difficulty chewing certain foods. Despite these findings, the resident's MDS assessments inaccurately documented no difficulty chewing and no dental problems. The DNS confirmed the assessments did not accurately reflect the resident's dental condition.
A resident with chronic kidney disease and dementia, identified as being at increased risk for falls, did not have their call light consistently within reach as required by their care plan. Multiple observations found the call light out of reach, and staff confirmed both the resident's fall history and the expectation to keep the call light accessible, but acknowledged this was not always done.
A resident with anxiety and depression, who was cognitively intact and had specific leisure interests, was not provided with meaningful or preferred activities. Despite documented preferences for outdoor time and music, the resident reported frequent boredom and had minimal participation in activities, with limited documentation of engagement. The care plan included activities not aligned with the resident's stated interests, and staff acknowledged challenges in meeting individual preferences and documenting participation.
A resident with a history of stroke and diabetes, who reported worsening vision, was referred by the facility optometrist to a retina specialist, but no appointment was scheduled and the resident was not seen by a specialist. Despite repeated requests to staff over several months, the resident did not receive the necessary vision care, and staff confirmed that no appointment had been arranged.
A resident with a history of stroke and diabetes, who was missing most of their teeth and required dental care, repeatedly requested assistance from the Social Service Director to schedule an outside dental appointment for tooth fragment removal and denture fitting. Despite these requests and staff awareness, no dental appointment was scheduled, and the resident's medical record showed no evidence of dental services being provided.
A resident with depression and scoliosis was physically abused by another resident with a history of stroke, who entered the resident's room, pushed them onto the bed, and held the door shut from the outside. The incident was confirmed by the facility administrator following the resident's report to staff and law enforcement.
A resident was physically pushed onto a bed by another resident, who then held the door shut to prevent exit. Although staff were aware of the incident, the administrator was not informed until several hours later, resulting in a late submission of the required abuse report to the state agency.
The facility did not ensure that daily nurse staffing postings were accurate and complete, with multiple days showing missing or incomplete information such as nurse and CNA hours, census data, dates, and required signatures. These deficiencies were confirmed by the staffing coordinator during a review.
A resident with a mental health diagnosis and history of exit-seeking behavior eloped from the facility after being left unsupervised at the front door when a CNA briefly left to notify a nurse. The resident, who was cognitively impaired and refused medications, was later found by police several blocks away. Staff interviews confirmed that 1:1 supervision was required but not maintained at the time of the incident.
A resident with diabetes and end stage renal disease, identified as a fall risk, was left unattended for an extended period after using the call light to request transfer assistance. Due to lack of staff response, the resident attempted to self-transfer from a bedside commode, resulting in a fall and a fractured femur. Staff interviews confirmed that the assigned CNA was absent from the unit, and other staff were either unaware or occupied with other duties, leading to inadequate supervision and delayed assistance.
A resident with a history of aggressive behavior and alcohol dependence physically assaulted another resident following a verbal altercation, despite existing behavioral care plans instructing staff to intervene. Staff and clinical documentation confirmed the aggressor had been drinking and that the altercation escalated to physical abuse, with no injuries reported.
A resident with atrial fibrillation did not receive prescribed apixaban for several days after returning from a hospital stay, due to the admitting nurse failing to input the medication order. The medication was marked as on hold in the MAR without explanation, and staff confirmed there was no physician order to hold the drug. The error was recognized as a significant medication error by facility staff.
A resident with severe cognitive impairment and a high risk of elopement was not provided with the necessary interventions outlined in their care plan. Despite being observed near the facility's entrance, staff failed to engage or redirect the resident as required, until the Activities Director intervened. The facility administrator was informed of these findings.
A resident with severe cognitive impairment and a history of elopement risk managed to leave the facility undetected and was found at a bus stop several blocks away. Staff interviews revealed inconsistencies in supervision and redirection strategies, and the facility's investigation lacked thoroughness, failing to address the root cause of the security lapse. No management staff were present post-incident, and key staff involved in the search were not interviewed.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to provide written or verbal responses to concerns raised by resident council members during two of four reviewed meetings. According to facility policy, a Resident Council Response Form should be used to track issues and their resolution, with the relevant department responsible for addressing concerns. However, review of meeting records from two specific dates showed that concerns such as lack of toenail care, staff performance, facility cleanliness, care conferences, snack accessibility, outdoor access, food temperature, fresh fruit availability, community outings, lost clothing, unanswered call lights, and staff responses to concerns were documented but not addressed. No evidence was found of any responses being provided to the resident council regarding these issues. Interviews with staff and residents confirmed that concerns were recorded and shared with appropriate departments, but no follow-up or feedback was given to the resident council. The Activities Director stated she forwarded concerns to the relevant departments but did not receive any responses. Residents reported submitting concerns in writing but not receiving any feedback. Department heads, including the DNS, Dietary Manager, and Housekeeping Manager, indicated they either did not receive the concerns or were not instructed to provide written responses. The Administrator confirmed that while concerns were discussed among staff, no direct communication was provided to the resident council for the meetings in question.
Failure to Communicate Grievance Resolutions to Resident
Penalty
Summary
The facility failed to provide a written grievance resolution or communicate the outcome of a grievance to a resident or the resident's representative regarding missing personal property. According to the facility's policy, grievances are to be documented and resolved within five working days, with outcomes communicated to the resident. Record review showed that a resident with diagnoses of depression and anxiety, who was cognitively intact, reported multiple missing items and stated that staff were aware of the concerns but did not inform the resident about any investigation or resolution. A review of the grievance binder revealed four grievances submitted by the resident, none of which included documented resolutions, signatures, or evidence that the resident was notified of the investigation results. The Social Services Director confirmed responsibility for grievance follow-up but acknowledged the forms were incomplete and could not provide evidence of resident notification. The Administrator also confirmed that the grievance process was not followed, and forms were not completed as required.
Failure to Maintain Sanitary Kitchen Conditions Due to Pest Infestation and Odor
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen food preparation areas in a clean and sanitary condition. During multiple kitchen inspections, hundreds of small bugs with wings were seen on the windowsill above the food prep sink, in the food prep sink, and on the steel counter where food was prepared. Additionally, a bug trap on the windowsill contained hundreds of bugs, and bugs were observed flying near the clean food prep area and inside the sanitary cleaning bucket used for wiping down food prep surfaces. The caulking along the windowsill above the food prep sink was missing and uncleanable, and a rancid odor was noted coming from under the food prep sink. Staff interviews confirmed that the issue with the bugs had been ongoing, with the bugs swarming the window and windowsill, migrating to the food prep sink and counters, and even biting kitchen staff. Staff also confirmed that the rancid smell under the food prep sink had persisted for some time, despite attempts to identify and treat the source, and described the odor as resembling that of a dead animal. These conditions were directly observed and confirmed by staff, indicating a failure to control pests and maintain sanitary food preparation areas as required by professional standards and the FDA Food Code.
Failure to Return Resident's Power Wheelchair After Discharge
Penalty
Summary
A resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, was admitted to the facility in March 2024 and utilized a personal power wheelchair. Upon transfer to a hospital and subsequent discharge to another facility in May 2024, no attempt was made by the facility to return the resident's power wheelchair. Interviews with the Social Service Director and Maintenance Director revealed that the wheelchair was stored in a shed for six months after the resident's discharge and was ultimately disposed of during a storage area cleanup in October 2024. The Administrator confirmed that the wheelchair, found to be non-operational, was not returned to the resident.
Failure to Maintain a Homelike and Clean Environment in Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a homelike environment in two of three hallways reviewed. In one instance, a resident with congestive heart failure and a BIMS score indicating cognitive intactness had a personal fan on the bedside table that was coated with a thick, visible accumulation of dust, lint, and grime on the blades and protective grill. The resident reported wanting the fan cleaned and had been waiting for staff to do so. The Housekeeping Supervisor confirmed that housekeepers were responsible for cleaning personal fans, and the Administrator acknowledged the fan needed cleaning and expected all personal fans to be clean. Additional observations between multiple dates revealed several resident rooms with environmental deficiencies, including walls with numerous scrapes, areas requiring painting, residual masking tape, missing and uncleanable wood on closet drawers, holes in walls, patched areas needing paint, and deep scrapes. Other issues included multiple screws and nails in walls, splashes and streaks of unknown substances, dust build-up on ceiling vents, sticky bedside tables, and malfunctioning table wheels. Residents in these rooms stated their rooms required cleaning and repairs and were not homelike. The Maintenance Director and Administrator both confirmed that the identified rooms required repairs, painting, and updating to meet homelike standards.
Inaccurate MDS Assessment of Dental Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for a resident with a history of stroke who was admitted in April 2020. Observations on two separate occasions revealed the resident had no upper teeth, missing lower molars, and experienced difficulty chewing certain food textures such as cucumbers and large pieces of lettuce. The resident reported missing upper teeth with three broken tooth fragments and missing teeth on both sides of the lower mouth, as well as difficulty chewing hard food items. However, the resident's quarterly and annual MDS assessments indicated no cognitive impairment, no difficulty chewing food, and no natural teeth or tooth fragments, with no obvious or likely broken natural teeth. The Director of Nursing Services confirmed that the MDS assessments were inaccurate and did not reflect the resident's actual dental status.
Failure to Ensure Call Light Accessibility for Resident at Risk for Falls
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with chronic kidney disease and dementia who was at increased risk for falls. Despite the care plan specifying that the resident's call light should be kept within reach and that the resident should be encouraged to use it for assistance, multiple observations on different occasions showed the call light was out of reach. Staff interviews confirmed that the resident had experienced recent falls and was capable of using the call light, and staff were expected to ensure the call light was accessible during every room entry. However, staff acknowledged that the call light was not always within the resident's reach, as required by the care plan.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
A resident with diagnoses of anxiety and major depression, assessed as cognitively intact, was admitted to the facility and identified specific leisure interests as very important, including going outside for fresh air and engaging in favorite activities. The resident's activity assessments indicated independence in leisure pursuits and enjoyment of music, outdoor activities, television, socializing, and helping others. Despite these documented preferences, observations over several days revealed the resident was not engaged in meaningful or preferred activities, except for attending one Bingo group. The resident reported frequent boredom and a lack of interest in the group calendar activities, with limited access to music in their room. Review of activity participation records showed minimal involvement in both group and individual activities. The care plan included religious activities, despite the resident indicating religion was not important, and there was a lack of documentation regarding activity participation. The Activity Director acknowledged the difficulty in planning activities to meet all residents' interests and confirmed the lack of documentation for this resident. The Administrator also recognized the need for improvement in providing personalized activities and ensuring documentation of resident participation.
Failure to Arrange Vision Services for Resident with Declining Vision
Penalty
Summary
The facility failed to obtain necessary vision services for a resident with a history of stroke and diabetes, who was experiencing a continual decline in vision. According to the facility's policy, staff are responsible for assisting residents in locating resources, scheduling appointments, and arranging transportation for vision care. Documentation showed that the facility optometrist referred the resident to a retina specialist, but there was no evidence in the electronic health record that an appointment was scheduled or that the resident was seen by the specialist. The resident's care plan also indicated that staff would arrange a consultation with an eye care practitioner as required, but this was not carried out. The resident reported repeatedly asking the Social Service Director over a four-month period to schedule an appointment with an eye doctor due to worsening vision, but no appointment was made. The resident was observed wearing non-prescription reading glasses and stated they did not have prescription glasses. Both the Social Service Director and the Director of Nursing confirmed that no appointment had been scheduled for the resident to see an eye doctor, despite being aware of the resident's requests and ongoing vision concerns.
Failure to Obtain Dental Services for Resident
Penalty
Summary
The facility failed to obtain necessary dental services for a resident who had been admitted with a history of stroke and diabetes. The resident's care plan indicated significant dental needs, including missing upper teeth and most lower teeth, with interventions specifying coordination of dental care and transportation. Despite these documented needs, there was no evidence in the resident's medical record that a dental appointment had been scheduled or completed. Observations confirmed the resident was missing upper teeth and had chipped and worn lower teeth. The resident reported repeatedly requesting assistance from the Social Service Director over a four-month period to schedule an appointment with an outside dental provider for removal of tooth fragments and remaining lower teeth, in order to be fitted for dentures. Both the Social Service Director and the LPN-Care Manager acknowledged awareness of the resident's requests but confirmed that no appointment had been scheduled. The Director of Nursing Services also confirmed that the dental appointment had not yet been arranged and stated that it should have been scheduled more promptly.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of depression and scoliosis was physically abused by another resident who had a history of stroke. According to the facility's investigation, the incident took place when the resident awoke early in the morning to find the other resident in their room. Upon attempting to stand, the resident was pushed back onto the bed by the other resident, who then held the door shut from the outside. The affected resident subsequently called the police and informed staff of the incident. The facility administrator confirmed that physical abuse had occurred during this event.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse within the mandated timeframe for one resident. According to the facility's policy, staff are required to report allegations of abuse promptly. On the date in question, a resident entered another resident's room, pushed the resident onto the bed, and then held the door shut from the outside, preventing the resident from leaving. Staff were aware of the incident at 4:00 AM, but the administrator was not informed until approximately 9:30 AM during a morning meeting. The Facility Reported Incident (FRI) was subsequently submitted late to the state agency, as confirmed by the administrator. This delay in reporting did not comply with the facility's abuse prevention policy.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Direct Care Staff Daily Report (DCSDR) postings for 15 out of 45 days reviewed. Specific issues identified included missing or incomplete licensed nurse staff hours, absence of CNA hours, missing census data, incorrect dates, and missing signatures on the DCSDRs. These deficiencies were confirmed during a review of the reports by the Human Resources/Staffing Coordinator, who verified the inaccuracies and incomplete information on the specified dates. This failure resulted in the posting of inaccurate staffing information, as evidenced by the review of records and staff interviews.
Resident Elopement Due to Lapse in 1:1 Supervision
Penalty
Summary
A resident with a long history of mental health issues and houselessness was admitted to the facility and assessed as being at risk for elopement. The resident's care plan included interventions such as regular monitoring, redirection, offering food and fluids, providing activities during wandering or exit-seeking episodes, and 1:1 supervision until exit-seeking behavior resolved. The resident was noted to be cognitively impaired, with poor decision-making skills, and was able to ambulate independently without an assistive device. The resident also refused medications, resulting in hallucinations and an inability to ask for assistance. On the night of the incident, the resident was observed by the front door, with a CNA assigned to monitor them. The CNA was not positioned closely due to the resident's preference for personal space. At some point, the CNA left the resident unattended for a brief period to notify the nurse that the resident was attempting to leave. During this time, the resident exited the facility without staff knowledge. Staff searched the facility and surrounding neighborhood but were unable to locate the resident, and the police were notified. The resident was later found by police several blocks away, sitting on a private residence's porch. Facility staff attempted to persuade the resident to return, but the resident refused and expressed a desire not to return. Interviews with staff confirmed that 1:1 supervision was expected when the resident exhibited exit-seeking behavior, and that the resident was left unsupervised at the door, which allowed the elopement to occur.
Failure to Provide Timely Transfer Assistance Results in Resident Fall and Fracture
Penalty
Summary
A resident with diabetes and end stage renal disease, identified as a fall risk due to medical conditions, lack of safety awareness, and poor impulse control, was not timely assisted with a transfer. The resident's care plan included interventions such as keeping the call light within reach and anticipating needs. On the evening of the incident, the resident used the call light and requested assistance from the night nurse, who was occupied with wound care. After waiting for approximately 45 minutes without staff response, the resident attempted to self-transfer from the bedside commode to the bed, resulting in a fall. Staff interviews revealed that the assigned CNA did not respond to the call light because he had left the facility to search for an eloped resident, and was unaware of the resident's need for assistance. Other staff members were either not aware of the situation or were engaged in other tasks. The resident was found on the floor after the fall, subsequently hospitalized, and diagnosed with a fractured femur. The facility's failure to provide timely assistance and adequate supervision directly contributed to the resident's accident and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, with a known history of aggressive behaviors and alcohol dependence, physically assaulted another resident. The aggressor had a behavioral care plan in place instructing staff to remove other residents or the aggressor from the area if aggressive or verbally inappropriate behaviors occurred. On the day of the incident, the aggressor had been drinking and engaged in a verbal altercation with another resident near the smoking area, which escalated to the aggressor punching the other resident in the face. Staff and clinical notes confirmed that the aggressor had been drinking and that the altercation resulted in a physical assault, though no injuries were noted. The resident who was assaulted had a behavioral care plan addressing high anxiety due to a history of homelessness and medical conditions, with staff directed to provide mental health support. Despite these care plans, staff did not prevent the altercation, and the resident was struck in the face after requesting the aggressor to pick up cigarette butts. Multiple staff interviews confirmed the sequence of events, the aggressor's history of aggressive behavior, and the failure to prevent the physical abuse.
Failure to Administer Anticoagulant Following Hospital Readmission
Penalty
Summary
A resident with a diagnosis of atrial fibrillation was admitted to the facility with physician orders to receive 5 mg of apixaban twice daily. Following a hospitalization for pneumonia, the resident was readmitted to the facility with discharge orders to continue apixaban. However, the medication was not administered from the date of readmission through several days afterward, as documented in the Medication Administration Record (MAR), which showed the medication was on hold without any nursing notes explaining the reason. The admitting nurse did not input the apixaban order upon the resident's return, and there was no physician order to hold the medication. The resident reported to a complainant that they had not received their blood thinner since returning from the hospital and expressed concern about being taken off the medication. Facility staff confirmed that the apixaban was not administered until several days after readmission, and the medication could have been accessed from the emergency medication kit if not available. The physician verified that the medication was not supposed to be held, and the error was acknowledged by facility staff as a serious medication error.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as a high elopement risk. The resident, who was admitted in May 2024 with diagnoses of schizophrenia and dementia, had a BIMS score of 0, indicating severe cognitive impairment. An elopement risk evaluation conducted in August 2024 confirmed the resident's high risk of elopement, as they frequently stood by the entrance door expressing a desire to leave. The care plan, dated October 2024, included interventions such as distracting the resident with diversions, activities, food, conversation, television, or a book. However, during the survey, staff members were observed failing to implement these interventions, as the resident was seen seated by the front door without any staff attempting to distract or provide a diversion. Multiple staff members, including CNAs and a Physical Therapist, were present in the area but did not engage with the resident as per the care plan. The resident was observed writing in a notebook and watching staff enter and exit the facility, but no attempts were made to redirect or engage the resident until the Activities Director offered a drink, which the resident accepted. The facility administrator was informed of these findings, but no additional information was provided to address the lack of implementation of the care plan interventions.
Inadequate Supervision and Investigation of Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and thoroughly evaluate an elopement incident involving a resident with severe cognitive impairment. The resident, diagnosed with schizophrenia and dementia, was identified as a high elopement risk and had a history of attempting to leave the facility. Despite this, the resident managed to elope from the facility and was found at a bus stop several blocks away, indicating a lapse in supervision and security measures. Interviews with staff revealed inconsistencies in the understanding and implementation of interventions to prevent the resident from eloping. Some staff members were aware of the resident's exit-seeking behavior but were unable to effectively redirect the resident. The facility's investigation into the incident was inadequate, lacking detailed documentation, including who conducted the investigation, when it was initiated, and whether key staff members involved in the search were interviewed. The facility's investigation report did not address the root cause of the security failure that allowed the resident to leave undetected. Additionally, no management staff were present at the facility following the elopement, and the investigation did not include interviews with the CNA staff who found the resident. This lack of thorough investigation and analysis of the incident placed residents at risk for future unsafe elopements.
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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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