Gracelen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 10948 S.e. Boise, Portland, Oregon 97266
- CMS Provider Number
- 38E188
- Inspections on file
- 27
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Gracelen Care Center during CMS and state inspections, most recent first.
The facility failed to timely report suspected resident-to-resident physical abuse to the proper authorities. Two residents, one with major depressive disorder and another with senile degeneration of the brain with anxiety and agitation, were involved in an altercation in which one resident struck the other with a reader stick after the other entered the room looking for personal items. A progress note documented that a resident reported being hit by another resident and was observed receiving a bandage to the knee. The Social Services Director completed an incident report and informed the administrator and DNS around midday, but the FRI was not submitted until several hours later, exceeding the required 2-hour reporting timeframe acknowledged by the DNS.
A resident with end stage kidney disease and diabetes became lethargic and unable to take medications, but despite repeated reports from staff, the responsible nurse did not perform or document a timely assessment, obtain vital signs, check blood sugar, or notify the on-call provider. The resident was later sent to the hospital at the family's request and diagnosed with sepsis due to a urinary tract infection.
A resident with multiple risk factors for pressure injuries was admitted with a sacral wound, but staff failed to perform a comprehensive wound assessment, notify the provider, or initiate timely wound care. After hospitalization and return with wound care orders, prescribed treatments for the sacrum and heels were delayed or not provided, and staff interviews revealed lapses in assessment, documentation, and care initiation.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility did not maintain RN coverage for eight consecutive hours on multiple days, as required, with staff and administrative acknowledgment of the deficiency. This resulted in a lack of appropriate RN presence to provide necessary care and assessments.
A resident was allegedly shoved into a wall by a roommate, and the incident was reported by a family member to facility staff. Despite being informed during shift change, an RN did not notify the State Agency of the abuse allegation and only reported it to the administrator and DNS after more than two hours. No report was made to the State Agency as required by policy.
A resident was moved to a new room after an altercation in which a former roommate allegedly shoved them into a wall. The incident was reported by a family member and known to staff, but a thorough investigation was not completed in accordance with the facility's abuse prevention policy.
Two residents with a history of stroke and dementia, both identified as high fall risks, were observed in bed without required fall mats in place. Staff interviews revealed a lack of awareness or failure to implement care plan interventions, and an LPN confirmed that the fall prevention measures were not followed as documented in the residents' care plans.
A resident with cognitive impairment and a history of falls was not provided with care planned fall prevention interventions, including a 'call don't fall' sign and a front wheel walker (FWW). Instead, the resident was observed ambulating with a wheelchair, and staff confirmed the absence of both the sign and the FWW, contrary to the care plan.
Three medication administration errors were observed, resulting in a 12% error rate. Two residents with diabetes did not receive insulin injections according to manufacturer instructions, as the LPN failed to hold the insulin pen in place for the recommended duration. Another resident prescribed Creon did not receive the medication with food, as required, because the CMA administered it without coordinating with meal times. The DNS confirmed that staff did not follow expected procedures.
Surveyors found an expired vial of tuberculin in the medication storage room refrigerator and observed that treatment carts containing medications and medical supplies, including insulin and needles, were left unlocked and unattended in two hallways. Staff and the DNS confirmed that these practices did not meet facility policy, which requires timely disposal of expired biologicals and that medication carts remain locked when not in use.
A resident with quadriplegia and multiple pressure ulcers received wound care from an LPN who failed to perform hand hygiene between glove changes, despite CDC guidelines requiring this practice. The LPN acknowledged only performing hand hygiene before and after the procedure, and the DON confirmed that hand hygiene should occur after glove removal during wound care.
A resident with vascular dementia and a hip fracture was threatened by a CNA for using the call light too much. The CNA told other staff to inform the resident they would be isolated without a call light if they continued. The incident was reported by two CNAs and confirmed by the resident, who experienced fear when the CNA turned off the lights. Management confirmed the occurrence.
A facility failed to document the reason for transferring a resident with traumatic brain injury and delirium to an acute care hospital and did not communicate necessary health information to the receiving provider. The resident's medical record lacked documentation on why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. The DNS acknowledged the missing discharge information.
The Dietary Manager failed to obtain the required certification to provide dietary management services. The Dietary Manager, who had been in the position since 4/2022, was observed providing services without the necessary certification. The Administrator confirmed awareness of this issue.
The facility failed to ensure nursing staff competencies for five staff members, placing residents at risk for poor quality of care. Incomplete or missing competency records were found for an RN and four other nursing staff members during a survey.
The facility failed to ensure that CNAs received their annual performance reviews, placing residents at risk for lack of care by competent staff. Personnel records showed that four CNAs had not received their evaluations, and the DNS confirmed awareness of this issue.
The facility failed to ensure proper infection control practices during medication administration and dining. An RN did not disinfect a glucometer or perform hand hygiene between residents, a CMA did not wash hands between handling medications for different residents, and a CNA did not change gloves or perform hand hygiene while assisting multiple residents with eating. The DNS acknowledged these lapses in infection control.
The facility failed to ensure that CNA staff received the required 12 hours of in-service training annually. Four out of five randomly selected CNAs did not meet the training requirements, with one completing 8.6 hours, another 0 hours, a third 9.10 hours, and the fourth 4 hours. The DNS confirmed the lack of compliance and acknowledged awareness of the issue.
The facility failed to maintain a homelike environment, with issues such as missing cove base, scrapes of missing paint, gouges of missing wood, and torn floor mats in resident rooms. The west hall sitting area and west dining room also had peeling wall coverings, cracks, and exposed screws, creating an unkempt environment.
The facility failed to protect residents from physical abuse, with multiple incidents involving residents with severe cognitive impairments physically assaulting each other. These incidents were witnessed by staff and confirmed by the facility administrator, highlighting a lack of adequate supervision and intervention.
The facility failed to report an incident of suspected abuse in a timely manner for two residents diagnosed with dementia. The residents were involved in an altercation where they were overheard yelling and observed hitting each other. The incident was not reported within the required two-hour timeframe, placing residents at risk for abuse.
The facility failed to ensure residents were treated with dignity during meal times, as staff members were observed standing while assisting residents with eating. Both a CNA and an RN acknowledged the lack of available stools as the reason for standing, despite knowing it was against policy.
The facility failed to obtain consent before administering psychotropic and antiviral medications to two residents. One resident with Alzheimer's disease received mirtazapine and quetiapine without documented consent, while another resident with anxiety and depression received clonazepam, Celexa, and asenapine without documented consent. Staff confirmed the lack of documentation and consent for these medications.
A resident with Parkinson's disease experienced leg pain due to exposed metal on her/his wheelchair and a missing arm rest pad. Despite the CNA reporting the issue to maintenance, the Maintenance Director was unaware, and the LPN Resident Care Manager observed indentations on the resident's calves, indicating a need for a cushion or wedge.
The facility failed to obtain consent, assess, monitor, and reevaluate the use of bolster pillows as restraints for a resident with severe cognitive impairment. Staff confirmed the use of pillows to prevent falls but acknowledged the lack of consent and proper documentation, placing the resident at risk for inappropriate restraint use.
A resident with schizoaffective disorder, bipolar disorder, and stroke was observed performing ADLs independently, despite their care plan indicating they required extensive assistance. Staff confirmed the resident's independence, but the care plan was not updated to reflect this, leading to a deficiency.
The facility failed to complete a discharge summary for a resident diagnosed with normal pressure hydrocephalus who initiated a discharge. The DNS was unable to provide the required documentation upon review.
The facility failed to follow physician orders for two residents, leading to unmet care needs. One resident did not receive prescribed medication for five days, and another resident's edema was not monitored as ordered. Staff and administration acknowledged these failures.
A resident with Alzheimer's disease was prescribed acyclovir without a clear indication, receiving the medication daily from January to April 2024. The medication was initially prescribed for chemotherapy that ended in August 2023, and staff later acknowledged it should not have been continued.
Failure to Timely Report Suspected Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an incident of suspected physical abuse between two residents to the proper authorities. Resident 6, admitted in 11/2024 with major depressive disorder, and Resident 7, admitted in 1/2026 with senile degeneration of the brain with anxiety and agitation, were involved in an altercation on 2/14/26 at 10:00 AM when Resident 7 struck Resident 6 with a reader stick after Resident 6 wandered into Resident 7’s room looking for personal items. A progress note entered on 2/14/26 at 12:28 PM documented that the Social Services Director (Staff 7) observed Resident 6 receiving assistance with a bandage to the knee, and upon inquiry, Resident 6 reported being hit by another resident after entering that resident’s room and approaching them. Staff 7 stated she completed an incident report regarding the event at approximately 12:00 PM on 2/14/26 and informed both the Facility Administrator (Staff 1) and the DNS (Staff 2) of the incident at that time. Despite this, the Facility Reported Incident (FRI) was not submitted until 2/14/26 at 6:27 PM, more than two hours after the facility became aware of the suspected abuse. On 3/10/26 at 12:26 PM, the DNS (Staff 2) acknowledged awareness of the incident and confirmed that allegations of potential abuse were required to be reported within two hours of occurrence, and further acknowledged that this incident was not reported within the required two-hour timeframe.
Failure to Timely Assess Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to assess a resident's change of condition in a timely manner. The resident, who had end stage kidney disease and diabetes and was admitted with moderate cognitive impairment, was observed by multiple staff to be lethargic, difficult to rouse, and unable to take medications. Despite these observations and repeated reports from a CMA and CNA to the charge nurse, there was no documented evidence that a physical assessment, vital signs, or blood sugar checks were performed, nor was the on-call provider contacted. The only recorded vital sign was a blood pressure reading several hours after the initial concern, and the resident was ultimately sent to the hospital at the family's request. Interviews with staff confirmed that the expected protocol for a change in mental status—such as immediate assessment, obtaining vital signs, checking blood sugar, and notifying the provider—was not followed. The nurse responsible did not document any assessment or communication with the provider, and the on-call provider confirmed they were not notified. The resident was later found to have sepsis due to a urinary tract infection upon hospital admission. Facility leadership acknowledged the lack of assessment and documentation in this incident.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat pressure ulcers for a resident admitted with significant risk factors, including end stage kidney disease, diabetes, decreased mobility, and incontinence. Upon admission, the resident was noted to have an unstageable sacral wound, but no comprehensive assessment was performed to document the wound's characteristics such as location, stage, measurements, tissue type, or other relevant details. There was also no evidence that the facility provider was notified of the wound, and no wound care or treatment was documented for the first six days following admission. Additionally, after the resident was hospitalized and returned with specific wound care orders for the sacrum and both heels, the facility failed to initiate or document the prescribed treatments in a timely manner. Treatment for the sacral wound was delayed by five days, care for the left heel was delayed by thirteen days, and there was no record of treatment for the right heel wound. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for wound assessment, documentation, and initiation of care orders. Staff acknowledged that required assessments and treatments were not completed as expected, and the resident's wound condition did not improve during their stay.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. Review of Direct Care Staff Daily Reports for the specified periods revealed that on eight separate days, there was no RN coverage for the required duration on any shift within a 24-hour period. This deficiency was confirmed through both record review and staff interviews, with the staffing coordinator acknowledging the lack of adequate RN coverage on the identified dates. The administrator also confirmed the expectation for appropriate RN staffing to provide necessary care and assessments for residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an incident of potential abuse involving a resident who was allegedly shoved into a wall by a roommate. The family member of the affected resident immediately informed facility staff about the physical altercation. However, the registered nurse on duty did not notify the State Agency of the abuse allegation, despite being informed of the incident during shift change. The nurse subsequently reported the allegation to the facility administrator and director of nursing more than two hours after becoming aware of it. The administrator confirmed that no report was made to the State Agency regarding the incident, which was contrary to the facility's abuse prevention policy requiring all suspected or alleged cases of abuse to be reported within the mandated two-hour timeframe.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into an allegation of abuse involving a resident who was reportedly shoved into a wall by a former roommate. According to the facility's Abuse Prevention Policy, all suspected or alleged cases of abuse are to be investigated thoroughly and completed within five days. Documentation showed that the resident was moved to a new room following the altercation, and a family member reported the incident to staff immediately. Staff interviews confirmed that the incident was reported and known to staff, but the administrator acknowledged that a complete investigation was not conducted as required by policy.
Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents identified as high risk for falls. One resident, admitted with a history of stroke and anxiety, was assessed as a high fall risk and had a care plan intervention requiring a fall mat to be placed at the bedside when in bed. On multiple occasions, this resident was observed in bed without a fall mat present. Staff interviews confirmed that the care plan was not being followed, and staff were either unaware of the required interventions or acknowledged that they were not implemented. Another resident, admitted with dementia and stroke, also had a care plan indicating a high fall risk and the need for a fall mat when in bed. This resident was observed on two separate occasions sleeping in bed without a fall mat in place. Staff interviews revealed uncertainty or lack of knowledge regarding the resident's fall interventions, and the responsible care manager confirmed the absence of the fall mat and was unable to locate one in the resident's room. These failures resulted in the care plans not being implemented as written.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions to prevent falls for a resident with cognitive impairment and a history of falls. The resident, diagnosed with fibromyalgia and admitted in January 2025, had multiple documented falls and was care planned to have a 'call don't fall' sign within eyesight and to use a front wheel walker (FWW) for ambulation. However, observations over several days revealed that the resident did not have the required sign posted in the room and was not provided with a FWW. Instead, the resident was seen using a wheelchair to ambulate to the restroom and reported not being offered a FWW. Interviews with staff confirmed the absence of the sign and the FWW, with multiple CNAs and an LPN stating that the resident was not given a FWW and that the sign was not present in the room. The Resident Care Manager acknowledged that the care plan required these interventions but was unaware that the resident was using the wheelchair for ambulation instead. These failures to follow the care plan placed the resident at risk for further falls and injury.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with three errors identified in 25 observed opportunities, resulting in a 12% error rate. During medication administration, staff did not follow manufacturer instructions for insulin pen use for two residents with type 2 diabetes mellitus. Specifically, the LPN administered insulin injections and immediately removed the needle from the skin without holding it in place for the recommended 10 seconds, as specified by the manufacturer. The facility's own policy also did not align with manufacturer instructions, indicating a five-second hold, but this was not followed either. The DNS confirmed that staff did not adhere to the expected safety steps for insulin administration. Additionally, a resident prescribed Creon for digestive support did not receive the medication with food, as required by both manufacturer instructions and physician orders. The CMA administered Creon without offering a snack or meal, and no food was present in the resident's room at the time. The CMA stated that coordinating medication administration with meal times was challenging, and referenced the facility's policy allowing a one-hour window before and after scheduled medication times. The DNS acknowledged that staff were expected to follow physician orders regarding medication administration with meals.
Expired Biologicals and Unsecured Medication Carts Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with professional standards. Specifically, an open vial of tuberculin used for tuberculosis testing was found in the medication storage room refrigerator past its expiration date. The Director of Nursing Services (DNS) confirmed that the vial was expired and acknowledged that staff are expected to discard such vials within 30 days of opening, as per facility policy. Additionally, treatment carts in both the East Hall and another hall were repeatedly found unlocked and unattended during multiple observations. These carts contained medications and supplies such as insulin, insulin pens, needles, oral medications, dressings, creams, and tube feeding medications. Staff, including LPNs and RNs, acknowledged that the carts should have been locked when not in use or when staff were not present. The DNS also confirmed the expectation that medication and treatment carts remain locked when unattended.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a staff member failed to perform hand hygiene during wound care for a resident with quadriplegia and multiple pressure ulcers. The resident had a history of four pressure ulcers upon admission and later developed an additional in-facility pressure ulcer. During observed wound care procedures, the LPN was seen removing and donning new gloves multiple times while providing care to wounds on the ischium and sacrum, but did not perform hand hygiene between glove changes as required by CDC guidelines. The LPN acknowledged performing hand hygiene only before and after the wound care treatments, not in between glove changes. The Director of Nursing Services confirmed that the expectation was for staff to perform hand hygiene after glove removal during wound care. This failure to follow proper hand hygiene protocol was observed and confirmed through staff interview and record review.
Failure to Protect Resident from Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from mental abuse by staff, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident diagnosed with vascular dementia and a hip fracture. The resident, who was cognitively intact according to their Admission Minimum Data Set (MDS), was reportedly threatened by a CNA for using the call light excessively. The CNA allegedly told other staff members to inform the resident that they would be placed in a room alone with the door closed and without a call light if they continued to use it too much. This behavior was reported by two other CNAs who witnessed the incident and immediately informed management. The resident confirmed the incident, stating that they were indeed threatened and that the CNA had turned off the lights on one occasion, causing the resident to scream until the lights were turned back on. This incident was corroborated by the Director of Nursing Services (DNS) and the Administrator, who confirmed that the event occurred. The report highlights a failure in the facility's responsibility to protect residents from mental abuse, placing them at risk for further abuse.
Failure to Document Transfer Basis and Communicate Health Status
Penalty
Summary
The facility failed to document the basis for the transfer of a resident and did not include necessary information such as the code and health status to the receiving provider. This deficiency was identified during an interview and record review, which revealed that the facility did not document the reason for the transfer of a resident with traumatic brain injury and delirium to an acute care hospital. The resident's medical record lacked documentation indicating why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. The Director of Nursing Services acknowledged the absence of discharge information in the resident's medical record.
Dietary Manager Lacks Required Certification
Penalty
Summary
The Dietary Manager failed to obtain the required certification to provide dietary management services. From 4/2/24 through 4/8/24, the Dietary Manager was observed providing services in the facility kitchen. On 4/5/24, the Dietary Manager stated he had been in the position since 4/2022 and had not completed the required certification. On 4/8/24, the Administrator confirmed awareness of the Dietary Manager's lack of certification.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
The facility failed to ensure nursing staff competencies for five sampled staff members, which placed residents at risk for poor quality of care. During interviews and record reviews on 4/4/24 and 4/5/24, it was found that the facility could not provide complete competency reviews for Staff 14 (RN) and had no competency records for Staff 22 (LPN), Staff 23 (LPN), Staff 24 (RN), and Staff 25 (RN). Staff 2 (DNS) and Staff 27 (Staffing Coordinator) were unable to provide the requested evidence of competencies, and Staff 1 (Administrator) confirmed the lack of documentation.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received their annual performance reviews, which placed residents at risk for lack of care by competent staff. Personnel records reviewed on April 5, 2024, with the Staffing Coordinator indicated that four CNAs (Staff 8, 17, 18, and 19) had not received their annual performance evaluations. Staff 8 had an adjusted seniority date of October 4, 2008; Staff 17, November 22, 2022; Staff 18, January 21, 2020; and Staff 19, October 9, 2021. The Staffing Coordinator confirmed the lack of completed annual performance reviews for these staff members. Additionally, the Director of Nursing Services (DNS) acknowledged awareness of the issue, confirming that many CNA staff, including the four mentioned, did not have their annual performance reviews completed.
Infection Control Deficiencies During Medication Administration and Dining
Penalty
Summary
The facility failed to ensure appropriate infection control practices during medication administration and dining, as observed in three staff members. One RN did not perform hand hygiene or disinfect a glucometer between uses for two residents, despite handling insulin and blood glucose monitoring supplies. The RN also failed to change gloves between residents and did not perform hand hygiene after removing gloves. This was confirmed by the RN, who admitted to not disinfecting the glucometer and misunderstanding glove use protocols. The DNS acknowledged the lack of appropriate infection control practices and stated the expected procedures for staff. Another staff member, a CMA, was observed administering medications without performing hand hygiene between residents. The CMA handled a resident's environment and medications with bare hands and did not wash hands before dispensing medications for another resident. The DNS was informed and acknowledged the lack of appropriate hand hygiene during medication administration. During a lunch meal observation, a CNA was seen repeatedly failing to perform hand hygiene between glove changes and while assisting multiple residents with eating. The CNA used the same gloves for different residents and did not wash hands after removing gloves. The CNA admitted to not consistently changing gloves between residents and not performing hand hygiene. The DNS confirmed that it was not acceptable for staff to wear the same gloves between residents and emphasized the importance of hand hygiene after removing dirty gloves and before putting on clean ones.
Failure to Ensure CNA Annual Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually. This deficiency was identified for four out of five randomly selected staff members. Specifically, one CNA completed only 8.6 hours, another had 0 hours, a third had 9.10 hours, and the fourth had 4 hours of annual training. The Director of Nursing Services (DNS) confirmed the lack of compliance with the training requirements and acknowledged awareness that the CNA trainings were not being completed.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as observed from 4/2/24 through 4/8/24. Specific issues included a section of missing cove base behind the door, scrapes of missing paint along the wall under the window, gouges of missing wood on the window sill, and a bedside table base covered with paint chips in one resident's room. Additionally, floor mats in multiple resident rooms were torn and tattered. The west hall sitting area had a 12-inch piece of wall covering peeling from underneath the window sill, a long crack in the wall with missing paint above the hand hygiene dispenser, and four large screws sticking out of the wall below the flag quilt. The west dining room had an area on the north wall with missing paint and brackets sticking out. These issues were acknowledged by the Maintenance Director on 4/8/24 at 11:31 AM, indicating an unkempt environment for the residents.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving residents with severe cognitive impairments. Resident 26, diagnosed with dementia and behavioral disturbance, physically assaulted Resident 4, who is cognitively intact, by punching them on the shoulder and face. This incident was witnessed by an LPN and confirmed by the facility administrator. Additionally, Resident 3, with severe cognitive impairment, and Resident 18, with a moderate risk for aggressive behavior, were observed hitting each other after a verbal altercation. This incident was also confirmed by the facility administrator and witnessed by a CNA who intervened to separate the residents. Another incident involved Resident 3 and Resident 46, both with severe cognitive impairments. Resident 3 punched Resident 46 after the latter attempted to place a cup on Resident 3's bed, leading to a physical altercation where Resident 46 retaliated by hitting Resident 3. This incident was witnessed by housekeeping staff and confirmed by the facility administrator. Despite these incidents, Resident 3 was observed walking unsupervised throughout the facility, and Resident 46 was seen sitting in their room with the door open, indicating a lack of adequate supervision and intervention to prevent further abuse.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report an incident of suspected abuse in a timely manner for two residents diagnosed with dementia. Resident 3 and Resident 18, both admitted in December 2020, were involved in an altercation on July 22, 2022, where they were overheard yelling and observed hitting each other. The incident was not reported within the required two-hour timeframe, as confirmed by the Administrator on April 5, 2024. This delay in reporting placed residents at risk for abuse.
Failure to Ensure Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal times in the East dining room. Observations made during the lunch meal revealed that staff members were standing while assisting residents with eating, which is against the facility's policy. Specifically, a CNA was seen standing over one resident while assisting with eating and simultaneously assisting another resident. An RN also stood while assisting a third resident at the same table. Both staff members acknowledged that standing while assisting residents was not dignified and attributed their actions to a lack of available stools. Interviews with the CNA and RN confirmed that staff were aware of the policy requiring them to sit and be face-to-face with residents during meal assistance. The CNA and RN both stated that there were not enough stools for all staff members to sit while assisting residents. The Director of Nursing Services (DNS) also confirmed that standing while providing eating assistance was considered a lack of dignity and that staff were expected to sit when assisting residents with their meals.
Failure to Obtain Consent for Medications
Penalty
Summary
The facility failed to ensure consent was obtained prior to administering psychotropic and antiviral medications to two residents. Resident 29, who was admitted with Alzheimer's disease, received mirtazapine and quetiapine from December 2023 to April 2024 without documented consent from the resident or the resident's spouse, who was the responsible party. Staff 12 and Staff 2 confirmed the lack of documentation regarding the risks, benefits, and potential side effects of these medications, as well as the absence of consent prior to administration. Similarly, Resident 12, admitted with anxiety disorders and depression, received clonazepam, Celexa, and asenapine in March and April 2024 without documented consent. Staff 3 acknowledged the absence of documentation indicating that the resident was informed of the risks and benefits of these medications and confirmed that consent was not obtained before the medications were administered. This failure placed the residents at risk of being uninformed about their medications.
Failure to Provide Reasonable Wheelchair Accommodations
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with Parkinson's disease, who was observed sitting in a wheelchair with her/his calves pressed against exposed metal and a missing arm rest pad. The resident reported leg pain, and staff confirmed the issue but had not addressed it. The CNA had reported the missing arm rest pad to maintenance, but the Maintenance Director was unaware of the issue. The LPN Resident Care Manager observed indentations on the resident's calves due to the exposed metal and acknowledged the need for a cushion or wedge to prevent further discomfort.
Failure to Obtain Consent and Monitor Restraint Use
Penalty
Summary
The facility failed to obtain consent, assess, monitor, and reevaluate the use of bolster pillows as restraints for a resident diagnosed with schizophrenia and dementia with behavioral disturbances. The resident, who had severe cognitive impairment, was observed with four bolster pillows placed on either side of their upper and lower body to prevent falls. However, there was no documented consent from the resident's representative for the use of these pillows, nor was there any assessment, monitoring, or reevaluation conducted for their continued use. Staff confirmed that the bolster pillows were used to prevent the resident from falling out of bed but acknowledged that consent had not been obtained and that no assessments or monitoring had been performed. This lack of proper documentation and oversight placed the resident at risk for inappropriate use of restraints, as the facility did not follow its own policy requiring written physician orders, consent, and regular reviews for restraint use.
Inaccurate Care Plan for Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect the needs of a resident. Resident 8, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and stroke, had a care plan indicating that they required extensive assistance for various activities of daily living (ADLs) such as toileting, dressing, personal hygiene, ambulation, bed mobility, and transfers. However, multiple observations over a week revealed that Resident 8 was independently performing these activities without assistance, contradicting the care plan's requirements. Staff interviews confirmed that Resident 8 was capable of completing most ADLs independently. A CNA reported that the resident only needed occasional checks and used a urinal that staff emptied. Another CNA stated that the resident changed their own brief and ambulated with a walker outside frequently. The LPN Resident Care Manager acknowledged that the care plan did not accurately reflect the resident's current level of ADL functioning. The Director of Nursing Services also expected the care plan to be accurate, indicating a failure in updating the care plan to match the resident's actual needs.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was admitted in October 2023 with diagnoses including normal pressure hydrocephalus. The resident initiated a discharge from the facility on January 14, 2024. Upon review of the resident's health record, it was found that there was no discharge summary documentation. On April 8, 2024, the Director of Nursing Services (DNS) was unable to provide the required discharge summary documentation for the resident.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to unmet care needs. Resident 19, diagnosed with Huntington's disease and receiving hospice services, had an order for glycopyrrolate to control oral secretions. The medication was prescribed on 3/29/24 but was not administered until 4/3/24, five days later. This delay was confirmed by the Hospice RN, the LPN Resident Care Manager, and the facility's Administrator and DNS, who acknowledged the failure to implement the medication order in a timely manner. Resident 8, diagnosed with schizoaffective disorder, bipolar disorder, and stroke, had a physician order from 1/18/24 to monitor bilateral lower leg edema every 12 hours. However, there was no evidence in the resident's health record that this monitoring was conducted. On 4/2/24, the resident's lower legs and ankles were observed to be swollen. Staff, including an LPN and the LPN Resident Care Manager, confirmed that the monitoring was not performed as ordered. The DNS also acknowledged the failure to follow the physician's order for monitoring the edema.
Unnecessary Medication Prescribed to Resident
Penalty
Summary
The facility failed to ensure that residents were not prescribed unnecessary medications, specifically for one resident diagnosed with Alzheimer's disease. The resident was admitted in December 2023 and had a physician's order for acyclovir, an antiviral medication, starting in January 2024. The order did not specify the disease for which the medication was prescribed prophylactically, and no further information or rationale was provided. The resident received acyclovir daily from January to April 2024 without a clear indication for its use. On April 5, 2024, a Licensed Practical Nurse (LPN) questioned the use of acyclovir and consulted the physician, who then ordered the medication to be discontinued. The LPN and the Director of Nursing Services (DNS) later reviewed the resident's records and found that the acyclovir was initially prescribed in conjunction with chemotherapy that had ended in August 2023. They acknowledged that the medication should not have been ordered or administered beyond that date, resulting in the resident receiving unnecessary medication.
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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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