French Prairie Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodburn, Oregon.
- Location
- 601 Evergreen Road, Woodburn, Oregon 97071
- CMS Provider Number
- 385117
- Inspections on file
- 29
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at French Prairie Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with COPD had physician orders for BID doses of Combivent, Symbicort, and apixaban. Review of the MAR showed the evening doses of all three medications were not administered as ordered, and the Interim DNS confirmed they were missed. This failure to follow the medication orders placed residents at risk for not receiving medications as prescribed and potential side effects.
Several residents expressed dissatisfaction with the meals, citing issues such as cold food, poor taste, and dry texture. Staff, including CNAs and LPNs, confirmed frequent complaints and noted that residents often ordered outside food due to the unpalatable meals. A test tray review with the Administrator revealed a cold, bland fish filet served without sauce.
The facility did not provide alternative meals to residents unless requests were made at least two hours in advance, as confirmed by multiple staff and resident interviews. Residents who did not like the main meal or requested alternatives outside the advance notice period were often unable to receive suitable options, despite the facility's alternative menu. This practice placed residents at risk of not receiving nourishing meals.
A resident with dementia and agitation physically struck a CNA and then alleged abuse by the CNA. An LPN assessed the resident and reported the allegation to management, but the facility did not report the abuse allegation to the State Agency within the required two-hour timeframe, and no investigation was initiated the same day.
A resident with dementia and a history of physical behaviors struck a CNA during care and subsequently alleged that the CNA had abused them first. The LPN notified management, but the facility's investigation was incomplete, lacking witness statements, investigation notes, and a summary, as confirmed by nursing leadership.
The facility did not maintain adequate nursing staff, leading to prolonged call light response times, delayed medication administration, missed meals, and incomplete care such as incontinence care and showers. Staff and family interviews, public complaints, and facility records all confirmed frequent staffing shortages, especially on nights and weekends, with state minimum staffing ratios for CNAs unmet on numerous days. One resident requiring substantial assistance reported long waits for care, and staff acknowledged that assignments were not made timely and inexperienced staff were orienting each other.
Facility administration did not ensure effective use of resources, resulting in chronic insufficient staffing, delayed resident assistance, and incomplete facility assessments. A resident with epilepsy did not receive seizure medication on time, leading to a seizure and hospitalization, with no incident report completed or follow-up with the responsible LPN.
A facility-wide assessment was found to be incomplete, lacking accurate information on how staffing needs and resident acuity were addressed, and failing to account for high agency staff usage. The Administrator confirmed the assessment was not comprehensive and did not contain accurate staffing data.
A resident with epilepsy and dementia experienced a seizure and was sent to the hospital, but the emergency contact was not notified by facility staff. The family member only learned of the incident from hospital staff, and facility leadership confirmed the lack of notification.
A resident with epilepsy and dementia did not receive scheduled anti-seizure medications on time when an LPN administered them several hours late and delayed documentation. The resident, who had no prior seizures in the facility, subsequently experienced multiple seizures and required hospitalization. The DNS was informed after a family member raised concerns, and no incident report or staff follow-up occurred.
The facility did not consistently post accurate and complete nurse staffing information, with multiple days showing blank or incorrect entries for daily census, staff numbers, and hours worked. This issue was confirmed by the Administrator.
Several residents with ongoing diarrhea and abdominal symptoms were not promptly assessed or reported to a physician, resulting in delayed c-diff diagnoses. Staff were observed not following required infection control protocols, such as washing hands with soap and water after caring for residents on contact precautions, and instead used alcohol-based hand rubs. Some staff were unclear about proper procedures, and others did not comply due to workload, leading to potential cross-contamination and an Immediate Jeopardy situation.
The facility did not maintain adequate CNA staffing levels, as evidenced by multiple shifts falling below state minimum requirements and numerous reports of long call-light response times. Residents needing assistance with lifts, ADLs, and eating experienced delays, and staff interviews confirmed high acuity and inability to complete all care tasks. Family and resident interviews, as well as direct observations, highlighted frequent and significant delays in care due to insufficient staffing.
The facility did not ensure RN coverage for at least eight consecutive hours per day on multiple occasions, as confirmed by review of staffing reports and administrator acknowledgment. This resulted in periods without required RN oversight, but no specific resident details were provided.
Annual performance reviews were not completed for four CNAs, as confirmed by interviews and record reviews. The Administrator and Regional RN could not provide documentation of these required evaluations when requested.
A resident with major depressive disorder was administered bupropion and desvenlafaxine daily without informed consent being obtained prior to the start of these medications. Consent forms detailing the risks and benefits were signed only after the medications had already been given, as confirmed by the DNS.
A resident with recent fractures and documented cognitive intactness was found to have been self-administering vitamins and eye drops brought from home without an interdisciplinary assessment or physician order, contrary to facility policy. Staff confirmed the absence of a required evaluation despite the resident's ongoing use of these medications.
A resident with severe cognitive impairment and multiple chronic conditions experienced two prolonged episodes of constipation without timely administration of prescribed bowel care medications or physician notification, as required by facility protocol. Documentation and monitoring were lacking, and staff could not provide evidence that the bowel care protocol was followed.
A resident with diabetes and bilateral cataracts did not receive follow-up for recommended cataract surgery after an eye exam, as the facility failed to schedule or address the surgery due to staff turnover and lack of a unit manager. The resident remained aware of the need for surgery but reported no further communication or action from staff.
A resident receiving regular dialysis treatments did not receive required post-dialysis assessments on multiple occasions, as confirmed by both the resident and staff interviews. Nursing staff failed to consistently assess and document the resident's condition and dialysis access site after each treatment, despite physician orders requiring these assessments.
A resident with a right ankle fracture and oral thrush did not receive prescribed Magic Mouthwash for throat pain over a period of several days because the medication was not available. An LPN contacted the pharmacy and provider about the missing medication, but the pharmacy did not receive necessary information from the facility to compound the medication, resulting in a significant delay in delivery. The DON confirmed the resident did not receive the medication as ordered.
A nurse administered two crushed medications together via a feeding tube to a resident with swallowing difficulties, contrary to facility policy requiring separate administration. This contributed to a medication error rate above the acceptable threshold.
A resident with multiple sclerosis and slow transit constipation did not have a physician-ordered stool sample collected for an IFOBT colorectal cancer screening test. Staff interviews revealed a lack of communication between charge nurses and CNAs regarding the need for sample collection, and the LPN was unsure if the order was properly relayed. The sample was not obtained as required by the physician's order.
A facility failed to notify a resident's representative in writing before a room change, as required by policy. The resident, who was severely cognitively impaired and had a spouse with POA, was moved after testing positive for COVID-19 without the spouse being informed. This led to conflict with the new roommate. Staff confirmed the notification protocol was not followed.
Two residents in a LTC facility were neglected by staff, resulting in one being left naked and covered in waste on the floor, and another falling after attempting to use the bathroom without assistance. Staff failed to provide proper care and timely response, leading to undignified and unsafe conditions for the residents.
An LPN in a facility failed to adhere to professional standards, resulting in the neglect of two residents. One resident with dementia was left naked and covered in waste on the floor, while another resident with muscle weakness and a hip fracture was left unchanged and fell in the bathroom. The LPN did not assess or document the incidents, and the facility's investigation confirmed neglect of care.
The facility failed to adequately assess and monitor pressure ulcers for three residents, leading to a risk of worsening wounds. A resident with diabetes and dementia had multiple wounds that were not properly assessed or treated. Another resident admitted to hospice care developed a pressure ulcer that was not monitored for several months. A third resident with a Stage 4 sacral ulcer had inconsistent and incomplete wound assessments. Staff acknowledged the deficiencies in monitoring and treatment.
Failure to Administer Ordered Respiratory and Anticoagulant Medications
Penalty
Summary
Facility staff failed to administer medications according to physician orders for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and had admission orders dated 12/26/25 for Combivent 1 puff BID, Symbicort 2 puffs BID, and apixaban 5 mg BID. Review of the December 2025 MAR showed that the evening doses of Combivent, Symbicort, and apixaban were not administered on 12/26/25 as ordered. In an interview on 2/27/26 at 9:39 AM, the Interim DNS confirmed that these medications were not given as ordered on that date. This failure to administer the ordered evening doses of respiratory inhalers and an anticoagulant placed residents at risk for not receiving medications as ordered and potential side effects, as identified through interview and record review.
Unpalatable and Improperly Served Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the food, describing it as cold, unpalatable, or unappetizing, with specific complaints including cold breakfast, dry chicken, and food described as 'nasty.' Staff members, including CNAs and LPNs, confirmed that residents frequently complained about the quality and taste of the meals and often resorted to ordering food from outside delivery services. During a test tray observation with the Administrator, a fish filet was found to be cold, bland, and served without any sauce, further confirming the issue.
Failure to Provide Timely Alternative Meals to Residents
Penalty
Summary
The facility failed to provide residents with alternative meals and snacks in accordance with their needs, preferences, and requests. Observations and interviews revealed that residents were required to request alternative meals at least two hours in advance, otherwise they had to wait until the end of meal service or were unable to receive an alternative meal at all. Staff members, including dietary, CNA, and LPN personnel, consistently stated that alternative meals could only be provided if requested well in advance, and some staff indicated that residents were not able to request alternatives at all. One resident reported being unable to get an alternative meal if they did not like what was served, and another stated they had only received a second tray once despite multiple requests. On one occasion, a resident requested a hamburger as an alternative meal, but the cook was unable to provide it because it was not on the product list and the request was not made two hours in advance. The facility's alternative menu listed several options, but staff confirmed that these were not always available unless pre-ordered. These practices placed residents at risk of not receiving nourishing meals, as the facility did not accommodate requests for alternative meals outside of the specified advance notice period.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe for one resident diagnosed with dementia and agitation. On the day of the incident, a CNA was physically struck by the resident, after which the resident alleged that the CNA had abused them first. The LPN assessed the resident and reported the allegation to facility management, but no staff initiated an investigation or ruled out the allegation within the mandated timeframe. The State Agency did not receive the facility's report of the abuse allegation until several hours after the incident, exceeding the required reporting window.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with dementia and agitation who had a care plan indicating a history of verbal and physical behaviors toward staff, requiring care to be provided in pairs. On the date of the incident, a CNA was physically struck multiple times by the resident during care. Shortly after, the resident admitted to hitting and kicking the CNA but also alleged that the CNA had abused them first. The LPN on duty notified facility management of the abuse allegation. The facility's investigation into the incident was incomplete, lacking staff witness statements, investigation notes, and a summary of the incident. Both the Director of Nursing Services and the Regional Director of Clinical later confirmed that the investigation was not thorough or complete. The documentation did not provide sufficient detail or evidence to demonstrate that the allegation of abuse was appropriately investigated.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On several occasions, residents experienced long call light response times, with documented waits of up to 33 minutes for assistance with basic needs such as toileting and receiving water. Family members and residents reported delays in medication administration, missed meals, and untimely incontinence care. Staff interviews confirmed ongoing shortages of CNAs, CMAs, and nurses, particularly on night and weekend shifts, resulting in incomplete care tasks such as showers, vital signs, and restorative care. Staff also reported that assignments were not made timely, residents were not divided evenly, and inexperienced staff were orienting each other. Public complaints submitted to the State Agency corroborated these findings, with allegations of untimely toileting assistance, long call light response times, and inaccurate reporting of CNA hours. Facility records showed that state minimum staffing ratios for CNAs were not met on 46 out of 115 days reviewed. Staff responsible for scheduling indicated that staffing decisions were based on minimum state requirements, and upper management determined when additional staff were needed based on acuity. However, there was acknowledgment from both staff and administration of ongoing staffing challenges and frequent call-ins, especially on weekends. One resident, admitted with a history of repeated falls and depression, required substantial assistance with transfers and toileting. This resident filed a grievance regarding insufficient night shift staffing and long call light response times, which was substantiated by facility records showing a CNA shortage on the reported date. The Director of Nursing Services stated she was not involved in staffing assessments, and the administrator confirmed that no facility assessment for staffing levels based on resident acuity was available.
Failure to Ensure Effective Administration, Sufficient Staffing, and Timely Medication Administration
Penalty
Summary
Facility administration failed to use resources effectively and efficiently, resulting in insufficient staffing, lack of a comprehensive facility assessment, and significant medication errors. Observations over multiple days revealed delayed responses to call lights, staff appearing rushed, and residents waiting for assistance, leading to resident frustration. Facility documentation and interviews with residents and staff confirmed ongoing concerns about inadequate staffing, with reports of staffing levels below state minimums and not adjusted for resident acuity. Staff reported these issues to administration, but no changes were made, and the facility assessment did not accurately address staffing needs or the high use of agency staff. Additionally, a resident with epilepsy did not receive scheduled seizure medication on time, with a dose administered over two hours late. Subsequently, the resident experienced an active seizure and was sent to the hospital. The DNS became aware of the incident only after a family member raised concerns, and no incident report was completed, nor was the responsible LPN interviewed about the event. These failures contributed to the facility not attaining or maintaining the highest practicable well-being of residents.
Incomplete Facility Assessment for Staffing and Acuity
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of the facility assessment dated 3/24/25 revealed it was not comprehensive and did not accurately include information on how the assessment was used to address staffing needs or resident acuity, nor did it reflect the high usage of agency staff. During an interview, the Administrator acknowledged that the assessment lacked accurate and comprehensive information related to staffing. No additional information was provided to address these deficiencies.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition for one resident who was admitted with diagnoses including epilepsy and dementia. According to the clinical record, the resident experienced an active seizure and was subsequently sent to the hospital by emergency services. Documentation showed that the on-call staff and the administrator were notified, but there was no evidence that the resident's emergency contact, a family member, was informed of the seizure or hospitalization. The family member later confirmed that she was unaware of the incident until contacted by hospital staff. Facility leadership acknowledged that the emergency contact was not notified regarding the resident's change in condition and hospitalization.
Significant Medication Error Leads to Resident Seizures and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with epilepsy and dementia did not receive prescribed anti-seizure medications (levetiracetam, lamotrigine, and zonisamide) at the scheduled time. The physician's order required these medications to be administered twice daily at 8:00 AM and 8:00 PM. On one occasion, an LPN administered the medications significantly late, at approximately 10:30 PM, and did not document the administration until 11:47 PM. Prior to this incident, the resident had no recorded seizures in the facility. Following the late administration, the resident experienced multiple seizures, including one lasting about ten minutes, and was subsequently sent to the hospital via ambulance. The DNS became aware of the incident after a family member raised concerns about the timing of medication administration. The DNS confirmed that timely administration of anti-seizure medications is important and noted that the facility was not conducting routine lab monitoring for levetiracetam levels. No incident report was completed, and the DNS did not discuss the event with the LPN involved.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information as required, as evidenced by a review of Direct Care Staff Daily Reports from June 2025 through September 23, 2025. On 47 separate days, portions of the required staffing forms were either left blank or contained inaccurate information, including the daily census, the number of working staff, and staff hours worked. This deficiency was confirmed during an interview with the Administrator, who acknowledged the incomplete and inaccurate reports for the identified dates.
Failure to Implement and Enforce C-Diff Infection Control Precautions
Penalty
Summary
The facility failed to identify, assess, treat, and implement appropriate contact precautions for residents exhibiting symptoms of Clostridioides difficile (c-diff), as well as failed to ensure staff followed proper infection control practices. Multiple residents with persistent loose stools and diarrhea were not assessed in a timely manner, and there was no evidence that physicians were contacted regarding these symptoms. In several cases, residents were only diagnosed with c-diff after being sent to the hospital, despite ongoing symptoms documented in their records. Staff were observed not following required infection control protocols for c-diff, including not washing hands with soap and water after providing care to affected residents. Instead, staff frequently used alcohol-based hand rubs (ABHR), which is not the recommended practice for c-diff. Some staff members were unclear about the correct hand hygiene procedures, and others cited being too busy to follow proper protocols. Contact precaution signage was present, but staff either misunderstood or did not adhere to the requirements, leading to potential cross-contamination between residents and clean areas such as linen closets. Interviews with staff and review of records revealed a lack of consistent assessment and communication regarding residents with repeated loose stools. The Director of Nursing Services (DNS) acknowledged that staff were not following appropriate infection control practices and that there were concerns about staff understanding and compliance with c-diff precautions. These failures resulted in an Immediate Jeopardy situation, as determined by surveyors, due to the risk of exposure and spread of c-diff among all residents.
Removal Plan
- Identify and assess residents with suspected c-diff. Place affected residents on contact precautions with appropriate signage and review by a physician.
- Sanitize or remove shared equipment from use by affected residents.
- Monitor affected residents.
- Inservice staff on c-diff precautions and infection control practices.
- Inservice oncoming staff prior to their shift.
- Inservice nurses on assessing residents with signs and symptoms of c-diff.
- Conduct PPE competency testing.
- Conduct infection control audits and monitoring.
- Report to QAPI.
- Governing body review.
- Retrain and discipline non-compliant staff members.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents across all three halls reviewed, resulting in delayed and unmet care needs. Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates over two separate periods. The facility assessment indicated ongoing analysis of staffing needs, but records and interviews revealed persistent shortages. Residents requiring assistance with mechanical lifts, two-person ADL support, and eating were affected, and several residents exhibited behaviors that required additional attention. Staff interviews confirmed that high acuity and inadequate staffing made it difficult to complete all required tasks, with CNAs reporting being overworked and unable to respond promptly to resident needs. Observations and interviews documented numerous instances of prolonged call-light response times, with some residents waiting over an hour for assistance. In one case, a call-light was obstructed from view, further delaying response. Family members and residents reported frequent long wait times, particularly in the evenings, and staff were observed to be visibly stressed and hurried. The scheduling coordinator acknowledged reliance on census-based staffing, use of agency and PRN staff, and efforts to fill shifts when staff called off, but the administrator confirmed ongoing staffing shortages and long call-light wait times.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present for at least eight consecutive hours per day, seven days a week, as required. Review of Direct Care Staff Daily Reports for the periods of August and September 2024, and March to April 2025, identified thirteen specific dates when there was no RN coverage. This deficiency was confirmed by the facility administrator during an interview, who acknowledged the absence of required RN coverage on the identified dates. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for four sampled certified nurse aides (CNAs) who were reviewed for sufficient and competent nurse staffing. The Administrator and Regional RN were unable to provide documentation of annual performance reviews for these CNAs, despite requests for records and hire dates. This deficiency was identified through interviews and record reviews, which confirmed that the required evaluations had not been conducted for the identified staff members.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident admitted with major depressive disorder. Physician orders for bupropion and desvenlafaxine were initiated, and the resident received these medications daily as documented in the medication administration records. However, the signed consents outlining the risks and benefits of these medications were not obtained until several weeks after administration had begun. This was confirmed by review of the medical record and acknowledged by the Director of Nursing Services.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A deficiency occurred when the facility failed to assess a resident for self-administration of medications as required by its policy. The resident, who was admitted with a left arm and left lower leg fracture following a motor vehicle accident and was documented as cognitively intact, had several bottles of vitamins and eye drops on the bedside table. The resident reported that these items were brought in by family and had been self-administered for several weeks without staff intervention or assessment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation before allowing self-administration of medications, no such evaluation was found in the resident's clinical record. Staff confirmed that the resident had been in possession of and using these medications without the required assessment or physician order. The deficiency was identified through observation, interview, and record review, with staff acknowledging the oversight in not completing the necessary evaluation.
Failure to Administer Bowel Care and Follow Physician Orders
Penalty
Summary
The facility failed to administer bowel care medication and follow physician orders for bowel management for one resident with severe cognitive impairment and diagnoses including dementia and multiple sclerosis. The facility's constipation protocol required specific interventions and physician notification if more than four days passed without a bowel movement. However, the resident experienced two separate periods of extended constipation—one lasting seven days and another lasting five days—without consistent administration of prescribed bowel care medications or documentation that the physician was notified as required. Review of the medication administration records showed that the resident received a Dulcolax suppository only after seven days without a bowel movement, and there was no evidence of bowel care medication being given during the second episode. Additionally, there was no documentation of monitoring, implementation of the bowel protocol, or physician notification for either occurrence. Interviews with nursing staff confirmed that the protocol was supposed to be followed, but no evidence was provided to show that it was implemented for this resident.
Failure to Provide Follow-Up for Cataract Surgery Recommendation
Penalty
Summary
The facility failed to ensure that a resident received appropriate follow-up for vision treatment and services as recommended by an eye care professional. The resident, who had a history of diabetes and was diagnosed with bilateral age-related cataracts, was advised to undergo cataract surgery according to an eye exam summary. However, there was no documentation that the facility scheduled or followed up on the recommended surgery. The resident, who was cognitively intact, reported that their vision was poor and that no one had discussed the surgery with them since the initial recommendation. Staff interviews revealed that the responsibility for scheduling follow-up visits typically fell to the unit manager, but due to staff turnover and the absence of a unit manager, the follow-up was not completed.
Failure to Complete and Document Post-Dialysis Assessments
Penalty
Summary
A resident with end-stage renal disease and dependent on dialysis was admitted to the facility and had physician orders specifying dialysis treatments three times weekly, with a requirement for post-dialysis assessments upon return to the facility. The resident's medical record review showed that the last documented post-dialysis assessment was completed on 3/24/25, with no evidence of assessments on thirteen subsequent dialysis dates. The resident confirmed that nursing staff did not assess them after returning from dialysis. Interviews with staff revealed that the agency RN reviewed paperwork and entered new orders upon the resident's return from dialysis but did not consistently document or perform post-dialysis assessments. The LPN Unit Manager acknowledged the lack of documentation for the required assessments and stated that nursing staff were expected to assess the resident, including the dialysis access site, and document these findings after each dialysis session.
Failure to Provide Timely Pharmaceutical Services for Pain Management
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident admitted with a right ankle fracture and oral thrush, who had an order for Magic Mouthwash to be administered four times daily for throat pain. According to the medication administration record, the mouthwash was not available from 4/10/25 to 4/23/25, and the resident did not recall receiving it during this period. An agency LPN reported contacting both the pharmacy and the provider on two occasions to notify them that the medication was unavailable. The facility pharmacist stated that the pharmacy had reached out to the facility on 4/14/25 to clarify the medication ratios needed to compound the mouthwash but did not receive a response, resulting in the medication not being delivered until 4/25/25. The Director of Nursing acknowledged that the resident did not receive the ordered medication as prescribed.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 7.69% error rate with 2 errors out of 26 observed medication administration opportunities. During medication administration, a nurse crushed and combined two medications—metoprolol tartrate and atorvastatin calcium—before administering them together via a feeding tube to a resident who was unable to swallow following a stroke. The facility's policy, dated March 2023, specified that crushed medications should not be combined for administration, whether given orally or through a feeding tube. The nurse acknowledged not being aware of this policy and administered the medications together, contrary to the physician's orders and facility protocol. The Director of Nursing confirmed that medications should be given separately with flushes between each.
Failure to Obtain Ordered Laboratory Stool Sample
Penalty
Summary
The facility failed to obtain required laboratory samples for one resident who had an active physician order for a stool sample to complete an IFOBT test for colorectal cancer screening. The resident, admitted with multiple sclerosis and slow transit constipation, had an order for the test starting in November 2024. Interviews revealed that certified nursing assistants (CNAs) were responsible for collecting stool samples when notified by the charge nurse, but one CNA did not recall being informed that a sample was needed for this resident. An LPN stated that collecting the sample was challenging due to the need for three separate samples and was unsure if the need for collection was communicated to CNAs. The LPN Unit Manager expected charge nurses to communicate such orders at the start of each shift, and the Director of Nursing Services (DNS) expected physician orders to be followed in a timely manner or the physician to be notified if not completed. Despite these expectations, the sample was not collected as ordered.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party in writing prior to a room change, as required by their Room Move Notification policy. This policy mandates that both the resident and their representative be informed in advance of a room move and receive a written explanation if the move is initiated by the facility. In this case, Resident 4, who was admitted with dementia and had a power of attorney (POA) for finances and care held by their spouse, was moved to another room after testing positive for COVID-19. However, there was no documentation indicating that the spouse, who was also the decision maker, was contacted or provided with written documentation regarding the room change. The deficiency was further highlighted when the spouse, referred to as Witness 4, confirmed not being notified of the room change, which subsequently led to conflict between Resident 4 and the new roommate. Staff 3, identified as the Social Service Director (SSD), acknowledged that the facility's protocol was not followed, as the resident's representative was neither notified nor provided with the necessary written documentation. This oversight placed the resident at risk for adjustment difficulties and delayed the responsible party's notification related to changes in room location.
Neglect of Residents in LTC Facility
Penalty
Summary
The facility failed to protect the rights of two residents, identified as Resident 17 and Resident 18, from neglect and deprivation of services. Resident 17, who had a history of dementia and a fractured femur, was found naked and covered in urine and feces on the floor of their room. Staff 7 (CNA) and Staff 8 (LPN) were responsible for the resident's care but left the resident on the floor for an extended period, citing the resident's combative behavior as the reason. The facility's investigation confirmed that the neglect occurred, as the resident was left in an undignified and unsafe condition, with a skin tear and signs of cold exposure. Resident 18, diagnosed with muscle weakness and a hip fracture, was also neglected. The resident was left unchanged for an extended period, with urine and dried feces on their body. The resident attempted to go to the bathroom without assistance due to a lack of timely response to their call light, resulting in a fall. Staff 8 failed to assess the resident's condition or document the incident, leaving the resident on the floor until the shift change. The facility's investigation substantiated the neglect by both Staff 7 and Staff 8, as the resident was left in a humiliating and unsafe condition. The facility's administration, including Staff 1 (Administrator) and Staff 2 (DNS), acknowledged the failures in providing proper incontinent care and ensuring the safety of both residents. The incidents highlighted a lack of appropriate response and care from the staff, leading to the residents being left in undignified and potentially harmful situations. The facility's investigation confirmed the neglect and the failure to adhere to professional standards of care.
Neglect of Care for Two Residents by LPN
Penalty
Summary
The facility failed to ensure that Staff 8, an LPN, adhered to professional standards of practice, resulting in the neglect of two residents. Resident 17, who had a history of dementia and falls, was found naked and covered in urine and feces on the floor of their room. Staff 8, along with Staff 7, left the resident in this condition for an extended period, citing the resident's combative behavior as the reason. Staff 8 did not assess the resident's needs or consider one-to-one care, and failed to document the incident. The resident was eventually assisted by Staff 11, who found the resident cold and with a skin tear, and administered medication to calm the resident. Resident 18, diagnosed with muscle weakness and a hip fracture, was also neglected by Staff 8 and Staff 7. The resident was left unchanged with urine and dried feces and was found on the floor in the bathroom after attempting to go to the bathroom without assistance. Staff 8 did not respond to the resident's call light in a timely manner and failed to assess or document the resident's condition after the fall. The incident report was incomplete, lacking an assessment of the resident's injuries and other necessary details. The facility's investigation substantiated the neglect of care for both residents. Staff 8 admitted to not documenting the incidents or assessing the residents, and acknowledged that leaving Resident 17 in such a condition violated professional standards of care. The facility's administration confirmed the failure to provide proper incontinent care and ensure the safety of the residents.
Failure to Monitor and Assess Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor pressure ulcers for three residents, leading to a risk of worsening wounds. Resident 22, who was readmitted with diabetes and dementia, had an unstageable coccyx wound and a deep tissue injury on the right malleolus. However, the facility did not complete assessments for the right heel and failed to provide measurements or descriptions for the coccyx wound. Hospital records later revealed additional wounds on the right foot and heel, which were not monitored or treated as per the facility's records. Staff acknowledged the lack of comprehensive weekly assessments and the absence of treatment orders for certain wounds. Resident 15, admitted with dementia and later to hospice care, developed a right heel unstageable pressure ulcer, but the facility did not conduct weekly wound assessments or monitoring from June to September. Similarly, Resident 13, with diabetes and a Stage 4 sacral pressure ulcer, had inconsistent and incomplete wound assessments. The facility failed to provide detailed wound characteristics or measurements, and assessments were not conducted regularly. Staff confirmed the lack of consistent monitoring for Resident 13's pressure ulcer.
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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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