Highland House Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants Pass, Oregon.
- Location
- 2201 Nw Highland Avenue, Grants Pass, Oregon 97526
- CMS Provider Number
- 385149
- Inspections on file
- 28
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Highland House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment experienced frequent loose stools over an extended period, yet staff continued to administer constipation medications such as Miralax and senna and did not consistently use PRN loperamide as ordered. CNA documentation showed repeated loose stools and frequent incontinence care, and CNAs reported notifying medication aides and nurses, but the MAR reflected ongoing bowel care medications and minimal use of antidiarrheal treatment. Standing orders required holding bowel care with new onset diarrhea, and the DNS stated she expected staff to follow these orders and use appropriate PRN medications when residents had loose stools.
A resident with Parkinson's Disease receiving hospice care was not treated with respect and dignity when a CNA flicked the resident's hand and made a retaliatory comment during an episode of agitation. The CNA stated the actions were meant to be playful, but the administrator confirmed the interaction did not uphold the resident's dignity.
A resident with a history of intestinal bypass and failure to thrive was not properly assessed for a facility-acquired pressure ulcer. Although initially noted to have a red coccyx and identified as at risk, later wound evaluation described features of a Stage 3 ulcer but lacked measurements, staging, and incorrectly documented the wound as present on admission. An LPN acknowledged these assessment errors and incomplete evaluation.
A resident with a J-tube for enteral feedings had the tube dislodged when a CNA removed a blanket during transport to the shower room, resulting in hospital transfer for tube replacement. The facility did not document any evaluation or investigation of the incident to determine the cause or prevent recurrence, and no incident report was completed.
A resident on hospice care was administered 7.5 ml (75 mg) of methadone instead of the prescribed 0.75 ml (7.5 mg) after a CMA, following instructions from an LPN, misinterpreted the medication order. The error led to the resident requiring naloxone and oxygen, and the hospice nurse remained for observation.
A facility failed to protect residents from sexual abuse, as a resident with altered mental status was observed engaging in inappropriate sexual contact with two other residents diagnosed with dementia. Staff intervened in both incidents, but the affected residents had no recollection of the events. The facility was found in non-compliance with regulatory requirements.
A male CNA in a LTC facility was found to have sexually abused six residents, leading to immediate jeopardy. The abuse involved inappropriate touching and penetration during incontinence care, causing significant psychosocial harm. The incidents were reported by the residents, confirmed through interviews, and resulted in the CNA's arrest.
The facility failed to update care plans and conduct timely care conferences for several residents, leading to deficiencies in care. A resident diagnosed with schizophrenia had their care plan updated eight months late, while another with dental partials did not have their care plan revised. A resident requiring oxygen therapy did not have this need reflected in their care plan. Additionally, care conferences were not conducted as required for three residents, with staff acknowledging the lapses.
The facility failed to implement pharmacy recommendations for four residents, leading to potential risks. A resident with anxiety and depression did not receive a recommended dose reduction of aripiprazole, and another with insomnia continued temazepam despite discontinuation advice. A cancer patient continued unnecessary medications, and a resident with asthma did not follow recommended inhaler use instructions. Staff confirmed delays in addressing these recommendations.
The facility's medication error rate was 7.41%, exceeding the acceptable 5% threshold. Errors included improper application of a pain patch for a resident with chronic pain and incorrect timing of thyroid medication administration for a resident with low thyroid levels. Staff inconsistencies and failure to adhere to prescribed orders contributed to these errors.
The facility failed to treat residents with dignity and respect, affecting four residents. A resident with cancer felt disrespected when a CNA interrupted a conversation. Another resident with pain reported rude comments about body odor from a CNA, causing anxiety. A resident with depression experienced sarcasm and rushing from the same CNA, despite management's awareness. A resident with a femur fracture was called 'trash' by a former Physical Therapy Assistant.
The facility failed to maintain a safe and homelike environment, with unpainted patches in residents' rooms and a wheelchair with rough tape. Additionally, residents experienced disturbances from loud noises at night, including staff conversations and squeaky carts. Despite complaints, no changes were made to address these issues.
The facility failed to address grievances from six residents regarding staff behavior and dignity issues. Despite residents expressing discomfort and filing grievances, the facility did not document or investigate these concerns, leaving them unresolved.
The facility failed to follow physician orders and monitor residents, leading to deficiencies in medication administration and resident care. A resident with anxiety and depression received metoprolol despite contraindicated vital signs, and another with diabetes missed multiple doses of Senna without physician notification. A cancer patient did not receive post-fall neurological assessments, and residents with infections and kidney disease experienced lapses in antibiotic administration and urine sample collection, respectively.
The facility failed to post accurate and complete staffing information, with missing census documentation on several shifts. Observations showed incomplete Direct Care Staff Daily Reports (DCSDR) posted by the nurses' station, lacking information on resident census, number of staff, and hours worked. The Administrator, DNS, and Regional Director of Clinical confirmed the expectation for accurate DCSDR posting within one hour of a shift change.
The facility did not ensure CNAs completed the required 12 hours of annual in-service training. Three CNAs, hired in different years, completed only 6 to 10 hours of training within their annual periods. This was confirmed by the Administrator, DNS, and Regional Director of Clinical.
The facility failed to inform residents and their responsible parties about the risks and benefits of medications and dietary non-compliance, leading to a lack of informed consent. A resident was prescribed antipsychotic medication without a documented diagnosis, another was non-compliant with a diabetic diet without proper documentation, and a third was given medications without consent from their responsible party.
The facility failed to maintain the privacy and confidentiality of resident records in the Social Services office. The Social Services Director's office was left open with no staff present, exposing a resident's electronic health record and other sensitive documents. Multiple staff and residents had potential access to these records. The Social Services Director admitted to leaving the door open, and the Administrator confirmed that resident records should be secured.
A facility failed to assess a scoop mattress as a potential physical restraint for a resident with brain damage and anxiety, who was at risk for falls. Despite interventions in place to prevent falls, the resident was observed using a scoop mattress without documented assessment. Staff confirmed that an evaluation should have been completed.
A facility failed to comprehensively assess a resident with Schizoaffective Disorder for behavioral health needs. Despite an Annual MDS assessment indicating no behaviors, observations and staff interviews revealed the resident exhibited behaviors such as swearing, smearing feces, and resisting care. The facility's administrator and DNS acknowledged the expectation for comprehensive assessments, which was not met.
A resident experienced a significant change in condition, including cognitive decline, increased depression, and a new diabetes diagnosis, but the facility failed to conduct a required Significant Change MDS assessment. Despite the resident's increased need for assistance and multiple falls, there was no documentation of a significant change assessment, which was acknowledged by facility staff during an interview.
A facility failed to refer a resident with schizoaffective disorder, bipolar disorder, and PTSD for a Level II PASARR evaluation, despite the resident's mental health diagnoses. The resident's Annual MDS inaccurately indicated no serious mental illness, leading to the absence of a necessary evaluation. Staff interviews confirmed awareness of the oversight and the need for an effective referral system.
A resident was prescribed aripiprazole for schizophrenia despite lacking a documented diagnosis of the condition. The resident's medical records and assessments indicated no history of schizophrenia, yet the medication was administered based on incorrect MAR instructions. Staff interviews revealed inconsistencies in the resident's symptoms, and the facility's administration recognized the need for further investigation.
A resident with dementia, who required corrective lenses for adequate vision, was observed without glasses due to a broken lens. The issue had been ongoing since at least December, but the Social Service Director was unaware until June, and no vision appointments were scheduled.
The facility failed to ensure a safe environment for three residents, resulting in multiple falls. A resident with cancer fell due to a poorly fitting mattress lacking nonslip material. Another resident with a stroke history fell while attempting to transfer without assistance, exacerbated by wearing regular socks instead of nonskid ones. A third resident, requiring a bedside commode, fell multiple times due to its absence, contrary to the care plan.
A facility failed to provide a diabetic nutritional supplement to a resident after their readmission, placing them at risk for weight loss. The resident, diagnosed with diabetes, was supposed to receive the supplement twice daily. However, after a hospitalization, the supplement was not restarted, as confirmed by an LPN.
A resident with cancer was using a nasal cannula connected to an oxygen concentrator, which had a thick layer of dust on its vent, indicating neglect in cleaning. The resident's clinical record lacked physician orders for oxygen, which staff confirmed were necessary for continued use. The Director of Nursing Services verified the absence of these orders.
A facility failed to provide trauma-informed care for a resident with PTSD, lacking individualized interventions for specific triggers. The resident's care plan included general strategies but did not address unique needs, and staff were unaware of specific PTSD-related behaviors or triggers. This deficiency placed the resident at risk for re-traumatization and decreased quality of life.
A CNA was observed transporting dirty linens without using a bag, contrary to infection control protocols. The CNA admitted to not having bags and acknowledged the requirement to bag linens before transport. Facility leadership confirmed the expectation for staff to follow this protocol.
A resident was administered antibiotics for a UTI without proper indication. The resident, admitted with a UTI diagnosis, showed increased confusion and was sent to the hospital. A urine culture indicated improper collection, yet antibiotics were given. The facility's policy required a 72-hour review of test results, which was not documented, and the results did not support antibiotic use.
A resident with moderate cognitive impairment fell out of bed shortly after admission, but the facility failed to notify the resident's emergency contact. The incident was confirmed by an LPN and acknowledged by the DNS, who stated that the emergency contact should have been informed.
The facility failed to report a resident-to-resident altercation and did not investigate an abuse allegation involving a resident who claimed to have been pushed by a CNA. Despite staff recalling the incidents, there was no documentation or care plan updates, and the abuse allegation was not properly addressed or reported to the state.
The facility failed to develop baseline care plans for two residents within 48 hours of admission. One resident, with kidney disease, lacked a care plan for dialysis, while another, with a femur fracture and dementia, had no care plan addressing fall risk or psychotropic medications. Staff acknowledged these omissions, which were not rectified in the required timeframe.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications. One resident with fractures did not receive oxycodone or Percocet as prescribed, leading to moderate to severe pain. Another resident with a femur fracture did not receive pain medication until the day after admission, despite requests. The DNS confirmed that the emergency medication kit was accessible, but the medications were not administered.
A resident with kidney disease missed a scheduled dialysis treatment due to the facility's failure to arrange transportation. Despite being aware of the need for transportation, the facility did not ensure the resident attended the dialysis session, as confirmed by staff and a dialysis RN.
Failure to Follow Bowel Care Orders and Manage Loose Stools Appropriately
Penalty
Summary
The deficiency involves the facility’s failure to follow physician standing orders and provide appropriate bowel care for two residents experiencing loose stools. Standing orders signed by the physician directed staff to hold bowel care medications if a resident developed new onset diarrhea. For one resident admitted with adult failure to thrive and moderate cognitive impairment, CNA documentation showed frequent loose stools on numerous shifts throughout the month, yet the MAR reflected continued administration of Miralax for several days and no documented administration of loperamide or any other medication to address the loose stools during that period. A physician follow-up note referenced an episode of loose stools to be managed with loperamide and a temporary hold of bowel medications, but there was no documentation that loperamide was actually given. CNAs reported repeatedly informing nursing staff about the loose stools, with one CNA stating she sometimes changed the resident three to five times per shift but could only document one episode, and the DNS stated she would have expected staff to use appropriate PRN medication as prescribed when the resident complained of loose stools. For a second resident with Alzheimer’s disease and severe cognitive impairment, CNA documentation also showed multiple episodes of loose stools over two consecutive months. Despite this, the MAR showed that Miralax and senna for constipation were administered almost daily during these periods, with only one documented instance of senna being held due to loose stools. Loperamide was ordered PRN for loose stools but was administered only twice in one month and not at all in the following month, even though CNA records indicated frequent loose stools. A CNA stated the resident had loose stools frequently and that she reported this to the medication aide, who in turn reported it to the nurse, while a CMA stated she did not recall seeing documentation of loose stools for this resident. The DNS stated she would have expected staff to stop administering Miralax and senna when a resident had loose stools.
Resident Not Treated with Respect and Dignity by CNA
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with respect and dignity. The resident, who had Parkinson's Disease, was on hospice services and exhibited agitation, including spitting on the ground and toward staff while being assisted to sit in a wheelchair. During this interaction, a CNA flicked the resident on the back of the hand and stated, 'If you're going to be mean to me, I'm going to be mean to you.' The CNA later explained that the action and comment were intended to be playful and to calm the resident, as they had a history of working together. The administrator confirmed that the resident was not treated with respect or dignity during this incident.
Failure to Accurately Assess Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess a facility-acquired pressure ulcer for one resident with a history of intestinal bypass and failure to thrive. Upon admission, the resident was noted to have a red coccyx, but the initial Minimum Data Set (MDS) indicated no pressure ulcers, despite the resident being at risk. A subsequent wound evaluation documented coccyx shearing with characteristics consistent with a Stage 3 pressure ulcer, including 90% granulation tissue, 10% slough, and light serosanguineous drainage. However, the evaluation did not include wound measurements or proper staging, and incorrectly recorded the wound as present on admission. The LPN Unit Manager later acknowledged these assessment errors and the lack of a comprehensive evaluation.
Failure to Investigate Dislodged Feeding Tube Incident
Penalty
Summary
A resident with a history of failure to thrive and malnutrition was admitted with a surgically placed J-tube for enteral feedings. During transport to the shower room, a CNA removed a blanket from the resident, at which point the J-tube became dislodged and fell out. The resident was subsequently transferred to the hospital for J-tube replacement. Review of the medical record showed no documentation that the incident was evaluated or investigated to determine how the J-tube became dislodged or to identify measures to prevent recurrence. The Director of Nursing Services confirmed that no incident report or facility investigation was completed, as the facility did not routinely investigate tubes that fell out. Family reported that staff told them the J-tube was pulled out when the blanket was removed.
Significant Medication Error Due to Methadone Overdose
Penalty
Summary
A significant medication error occurred when a resident, admitted with failure to thrive and receiving hospice care, was administered an incorrect dose of methadone. The hospice order on 3/20/25 instructed staff to discontinue the previous methadone order and increase the dose to 7.5 mg twice daily, specifying that 7.5 mg should be given as 0.75 ml. However, the medication administration record (MAR) indicated that the resident was given 7.5 ml (equivalent to 75 mg) of methadone at 8:00 PM on 3/20/25 by a certified medication aide (CMA). This error was based on a misinterpretation of the order, as the CMA consulted with the charge nurse (LPN), who reviewed the original order and instructed the CMA to administer 7.5 ml instead of the correct 0.75 ml dose. Following the administration of the incorrect dose, new hospice orders were issued for naloxone nasal spray and oxygen, and the methadone order was clarified to specify the correct volume. The resident required administration of naloxone and oxygen, and the hospice nurse remained with the resident for observation. The CMA later confirmed the error, and attempts to contact the charge nurse for further information were unsuccessful. The incident demonstrates a failure to ensure residents were free from significant medication errors due to miscommunication and improper verification of medication orders.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, affecting two of the three sampled residents. Resident 1, who was admitted with altered mental status, was observed on two separate occasions engaging in inappropriate sexual contact with other residents. On the first occasion, Resident 1 was seen with their hand down the front of Resident 2's pants while both were in wheelchairs in the hallway. On the second occasion, Resident 1 was found in bed with Resident 3, with their hand on Resident 3's penis. Both incidents were witnessed by staff members who intervened and separated the residents. Resident 2 and Resident 3, both diagnosed with dementia, had no recollection of the incidents. Interviews with the residents revealed that they were alert but not oriented to place or time, and they did not express concerns about their care or recall having roommates. Staff interviews confirmed the inappropriate contact and acknowledged the sexual abuse incidents. The facility was found in non-compliance with the regulatory requirement at F600 due to these events.
Sexual Abuse by CNA Leads to Immediate Jeopardy
Penalty
Summary
A facility employee, identified as a male CNA, was found to have sexually abused six residents, leading to an immediate jeopardy situation. The abuse involved inappropriate touching and, in some cases, penetration during incontinence care. The incidents were reported by the residents themselves, who experienced significant psychosocial harm, including increased anxiety and difficulty sleeping. The abuse was confirmed through interviews with the residents, the CNA, and facility staff, as well as law enforcement. Resident 6, who was alert and oriented, reported that the CNA entered her room every hour under the pretense of providing incontinence care and inappropriately touched her. Resident 7, diagnosed with PTSD and depression, reported being molested multiple times by the same CNA, who also touched himself during these incidents. Other residents, including those with diabetes and kidney failure, were also victims of similar abuse, although some were unable to be interviewed due to discharge or cognitive impairment. The facility's investigation revealed that the CNA admitted to the inappropriate sexual contact with multiple residents. The abuse occurred after the most recent annual recertification survey and before the current survey. The facility reported the incidents to the State Survey Agency and law enforcement, leading to the CNA's arrest and criminal charges.
Removal Plan
- Alleged perpetrator suspended
- Cognitively intact residents interviewed to ensure no additional residents were sexually abused
- Staff interviewed from various shifts and departments to ensure there were no observations or complaints of abuse with cognitively intact or cognitively impaired residents
- Provider and residents' families notified
- Care plans for the residents involved in the allegation updated to include female-only caregivers
- Residents involved in the allegation placed on alert charting and referred to the facility's psychologist
- Skin assessments focused on identifying sexual trauma conducted
- Local law enforcement notified
- Audits conducted with verification of sustained compliance
- Audit trends reported to facility QAPI for review and further recommendations
Deficiencies in Care Plan Updates and Care Conferences
Penalty
Summary
The facility failed to revise and update care plans for several residents, leading to deficiencies in care. Resident 16, diagnosed with schizophrenia in October 2023, had their care plan updated only in June 2024, approximately eight months later. This delay in updating the care plan was acknowledged by the facility's staff, including the Administrator and the Regional Director of Clinical, who stated that the care plan should have been updated sooner. Similarly, Resident 19, who had dental partials since April 2024, did not have their care plan revised to reflect this change, and staff were unaware of the resident's dental needs. Resident 51, who required oxygen therapy, did not have their care plan updated to include this need, despite being observed with a nasal cannula and having been administered oxygen since March 2024. Staff confirmed that the care plan was not revised to reflect the resident's oxygen requirements. Additionally, the facility failed to conduct timely care conferences for Residents 21, 49, and 25. Resident 21 had only one care conference shortly after admission, with no subsequent conferences documented. Resident 49's representative was unaware of any care conferences since admission, and Resident 25 had not had a care conference in six months, despite the expectation of quarterly meetings. The lack of timely care conferences and updated care plans for these residents indicates a systemic issue within the facility's care planning process. Staff interviews revealed inconsistencies in the scheduling and documentation of care conferences, with some staff unaware of the required timelines. The facility's failure to adhere to these timelines and update care plans as needed placed residents at risk for unmet care needs, as acknowledged by the facility's Administrator and Director of Nursing Services.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to follow pharmacy recommendations for four residents, leading to potential risks of adverse medication side effects. Resident 16, diagnosed with anxiety and depression, was recommended for a gradual dose reduction of aripiprazole, but the physician did not sign or provide a rationale for maintaining the current dosage. Additionally, an assessment for abnormal involuntary movement was due but lacked documentation of completion. Resident 33, with insomnia and anxiety, continued to receive temazepam despite recommendations for discontinuation or dosage reduction. The pharmacy's recommendation was not addressed promptly, with staff acknowledging delays in follow-up. Resident 51, diagnosed with cancer, continued to receive ferrous sulfate and docusate despite normal iron levels and ineffectiveness, respectively, with no documentation of the physician's decision to decline the pharmacy's recommendations. Resident 63, with anxiety and asthma, did not have the recommended mouth rinse after using Symbicort documented in the MARs until later, indicating a delay in implementing the pharmacy's advice. These oversights and delays in addressing pharmacy recommendations were confirmed by staff interviews, highlighting a pattern of inaction in responding to pharmacy consultations.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed rate of 7.41% due to two errors in 27 opportunities. One incident involved a resident with chronic pain who was prescribed a medicated pain patch to be applied to both knees. However, the patch was applied to the resident's right arm and right leg instead, based on the resident's preference, without clarifying the order with a physician. This deviation from the prescribed order was acknowledged by the staff involved, indicating a lack of adherence to the medication administration protocol. Another incident involved a resident with low thyroid levels who was prescribed levothyroxine, a hormone replacement medication. The medication was administered after the resident had consumed breakfast, contrary to the recommended practice of taking it on an empty stomach before meals. Staff members provided conflicting information regarding the timing of the medication administration, with some indicating it did not matter, while others stated it should be given before breakfast. This inconsistency in medication administration practices contributed to the facility's elevated medication error rate.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting four residents. Resident 51, who was cognitively intact and diagnosed with cancer, reported feeling disrespected when a CNA interrupted a conversation to pick up a lunch tray despite being asked to wait. The CNA acknowledged the interruption, and the facility administrator confirmed the incident. Resident 65, also cognitively intact and diagnosed with pain, reported a CNA made rude comments about their body odor, causing anxiety and fear of retaliation. The CNA admitted to making a comment about the resident's need for a shower, which was witnessed by another CNA who agreed the approach was offensive. The Director of Nursing Services noted previous concerns about the CNA's interactions with residents, leading to the CNA being moved to a different unit. Witness 2, a resident with depression, reported disrespectful behavior from the same CNA, including sarcasm and rushing during interactions. Despite management being aware of the issues, the CNA continued to be disrespectful, leading to multiple relocations within the facility. Resident 95, with a femur fracture, reported being called 'trash' by a former Physical Therapy Assistant, which was acknowledged by the administrator as inappropriate language.
Environmental and Noise Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 20's bathroom had a missing tile and an unpainted patched wall, which was acknowledged by the facility's administrator and maintenance staff. Similarly, Resident 29's room had an unpainted patch on the wall, and Resident 51's room had a patched area above the bed that had not been painted since admission. Maintenance staff indicated that patching was prioritized over painting, which contributed to the unhomelike conditions. Additionally, Resident 137's wheelchair armrests were covered with green tape, which was acknowledged by the LPN Resident Care Manager as potentially rough on the skin and difficult to clean. Resident 90 experienced disturbances due to loud noises at night, including fireworks, staff conversations, and the movement of carts with squeaky wheels. Despite complaints from residents and staff about the noise, no changes had been implemented to address these issues. The facility's administration acknowledged the expectation for quiet during sleeping hours, but the deficiencies persisted.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to provide a written grievance resolution or communicate effectively with residents or their representatives regarding the resolution of grievances. This deficiency was identified for six residents who had filed grievances related to abuse and dignity. For instance, Resident 8 expressed discomfort with a male CNA providing personal care and requested female CNAs. Despite this preference being communicated to staff, it was not documented in the care plan, and no written resolution was provided. Resident 90 reported that staff were rude and threw personal items, which was not investigated or documented as a grievance. The facility's staff, including the Administrator, acknowledged that the concern was not reported or addressed appropriately. Similarly, Residents 83, 84, 86, and 87 filed grievances about a CNA's rude behavior, but these grievances were not documented or investigated by the facility management. The report highlights a pattern of inaction by the facility in addressing grievances related to staff behavior and resident dignity. Despite multiple reports and grievances filed by residents, the facility failed to document, investigate, or resolve these issues, leaving residents' concerns unaddressed.
Failure to Follow Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to adhere to physician orders and monitor residents appropriately, leading to several deficiencies. Resident 16, diagnosed with anxiety and depression, was administered metoprolol tartrate despite blood pressure and heart rate readings that were outside the physician-ordered parameters. Additionally, the resident's heart rate and blood pressure were not consistently documented, and there was a failure to administer Furosemide as needed for fluid retention due to inadequate weight monitoring. Resident 33, with a diagnosis of diabetes, had a physician order for Senna, a laxative, which was not administered 32 times over a period of two months. Despite the resident's refusals, there was no documentation that the physician was notified, as required. Resident 51, diagnosed with cancer, experienced an unwitnessed fall, but the facility did not conduct the necessary neurological assessments post-fall, as indicated by the lack of documentation in the clinical record. Resident 133, admitted with an infection, did not receive prescribed antibiotics on multiple occasions, with no documentation to explain the missed doses. Resident 134, with kidney disease, experienced pain with urination, and a urine sample was ordered but not obtained, as there were no results documented. These failures in medication administration and monitoring placed residents at risk for adverse effects and demonstrated a lack of adherence to physician orders and facility protocols.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, which placed residents at risk for incomplete and inaccurate staffing information. A review of the Direct Care Staff Daily Reports (DCSDR) from May 9, 2024, through June 9, 2024, revealed missing census documentation on several shifts, including the day and evening shifts on June 5, the evening shift on June 6, and the night shift on June 8. Observations on June 11 and June 12 showed that the DCSDR posted by the nurses' station was incomplete, with missing information on resident census, number of staff, and hours worked for various shifts. During an interview on June 14, the Administrator, Director of Nursing Services (DNS), and Regional Director of Clinical confirmed that it was expected to have an accurate DCSDR posted within one hour of a shift change.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records for three out of five randomly selected staff members. Specifically, CNA Staff 3, hired in 2006, completed only 10 hours of training; CNA Staff 5, hired in 2010, completed six hours; and CNA Staff 6, hired in 2016, also completed 10 hours of training within their respective annual periods. This deficiency was confirmed during an interview with the Administrator, Director of Nursing Services (DNS), and Regional Director of Clinical, who acknowledged the expectation for staff to complete the mandated training hours.
Deficiencies in Informed Consent and Documentation
Penalty
Summary
The facility failed to adequately inform residents and their responsible parties about the risks and benefits associated with antipsychotic medications and dietary non-compliance, leading to a lack of informed consent and decision-making. Resident 16, who was admitted with anxiety and depression, was prescribed aripiprazole without a documented diagnosis of schizophrenia. There was no evidence that Resident 16 was informed of changes in diagnosis or medication dosage. Interviews with staff revealed that while residents were notified of changes, new consents were not completed, and documentation of notification was lacking. Resident 33, diagnosed with diabetes, was non-compliant with a diabetic diet, consuming excessive amounts of soda and fast food, resulting in consistently high blood sugar levels. Despite staff acknowledging the need for a risk and benefits form, it was not completed. Resident 335, with dementia, was prescribed quetiapine fumarate and sertraline without documented consent from the resident's son. The lack of informed consent and documentation for these residents highlights deficiencies in the facility's communication and documentation processes.
Failure to Maintain Privacy and Confidentiality of Resident Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records in the Social Services office. On June 14, 2024, at 10:18 AM, the Social Services Director's office was observed with the door open and no staff present. The left computer monitor displayed a resident's electronic health record, and the right monitor showed an open and accessible email. The office contained numerous papers with residents' names and information, including transportation forms, State of Oregon letters to residents, completed discharge checklists, completed requests to transfer, and individual resident care conference information. Between 10:18 AM and 10:38 AM, multiple staff and residents were observed in the vicinity of the office, with the potential to access the resident records. At 10:38 AM, the Social Services Director admitted to leaving the office door open to indicate her presence in the facility, acknowledging that unauthorized individuals could access the resident records. The Administrator confirmed the expectation that resident records should be secured and inaccessible to unauthorized individuals.
Failure to Assess Scoop Mattress as a Physical Restraint
Penalty
Summary
The facility failed to assess the use of a physical restraint for a resident who was reviewed for restraints. The resident, admitted in 2023 with diagnoses of brain damage and anxiety, had a history of multiple falls and was at risk for further falls due to balance issues and a seizure disorder. A care plan dated October 14, 2023, included interventions to mitigate fall risks, such as using a fall mat and ensuring commonly used items were within reach. However, during observations in June 2024, the resident was found in bed with a scoop mattress, which is a concave-shaped bed designed to prevent users from rolling off and falling. There was no documentation in the resident's clinical record indicating that the scoop mattress had been assessed for its potential as a physical restraint. Interviews with facility staff confirmed that an evaluation for the use of a scoop mattress would be expected.
Failure to Comprehensively Assess Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to comprehensively assess a resident with a diagnosis of Schizoaffective Disorder, who was admitted in 2017, for behavioral health needs. The resident's Annual MDS assessment on May 6, 2024, indicated moderately impaired cognition and no exhibited behaviors. However, observations on June 12 and 13, 2024, revealed the resident engaging in behaviors such as talking to themselves, swearing at staff, and interacting aggressively with objects and people. Staff interviews confirmed ongoing behaviors including swearing, clashing with a roommate, smearing feces, and resisting care by shouting and hitting staff. The facility's administrator and DNS acknowledged the expectation for comprehensive and accurate behavioral assessments, which was not met in this case.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a Significant Change Minimum Data Set (MDS) assessment within the required timeframe for a resident who experienced a significant change in condition. The resident was admitted in 2023 with a diagnosis of stroke and was initially assessed as cognitively intact, with no depression concerns, and requiring minimal assistance for personal care. However, by the time of the quarterly MDS assessment in May 2024, the resident's condition had deteriorated to moderately impaired cognition, increased depression, and a need for substantial assistance with personal hygiene. Additionally, the resident experienced frequent bladder incontinence, two or more falls, and was diagnosed with diabetes. Despite these changes, there was no documentation indicating that a significant change assessment was considered or conducted, placing the resident at risk for unassessed needs. During an interview, facility staff acknowledged the oversight but did not provide further information.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident with mental health diagnoses was referred for a Level II PASARR evaluation, which is necessary for individuals with serious mental disorders or intellectual disabilities. The resident, admitted in 2017, had diagnoses including schizoaffective disorder, bipolar disorder, and PTSD. Despite these conditions, the resident's Annual MDS from May 6, 2024, indicated they were not considered to have a serious mental illness, and consequently, no Level II PASARR was completed. A review of the resident's electronic health record confirmed the absence of a Level II PASARR referral or evaluation. Interviews with the Social Services Director and the facility's Administrator and DNS revealed awareness of the resident's mental health issues and acknowledged the lack of a completed Level II PASARR, indicating a need for an effective referral system.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice concerning the administration of medications for a resident diagnosed with anxiety and depression. The resident was admitted in 2023 and was prescribed aripiprazole, an antipsychotic medication, and escitalopram, an antidepressant, despite not having a documented diagnosis of schizophrenia. The March 2023 Medication Administration Record (MAR) incorrectly instructed staff to administer aripiprazole for schizophrenia, a condition not diagnosed in the resident's medical history. Throughout multiple assessments, including the Admission MDS and Quarterly MDS, the resident was noted to be cognitively intact without hallucinations, delusions, or behaviors indicative of schizophrenia. In October 2023, a nursing note added a diagnosis of schizophrenia, and the resident was prescribed aripiprazole for this condition. However, subsequent evaluations, including a psychiatric consultation and hospital history, did not support this diagnosis, and the resident denied any history of mental health treatment or hallucinations. Despite this, the facility's records indicated a diagnosis of schizophrenia as an admitting diagnosis created in October 2023. Interviews with staff revealed inconsistencies in the resident's reported symptoms and behaviors, with no observed hallucinations or delusions. The facility's administration acknowledged the need to investigate the resident's history further, but no additional information was provided.
Failure to Provide Corrective Lenses for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to necessary vision services, specifically corrective lenses, which resulted in unmet vision needs. Resident 20, who was admitted in 2021 with a diagnosis of dementia, was noted in a March 2023 quarterly MDS to have adequate vision with corrective lenses. However, by June 2024, it was observed that the resident's glasses were broken, and the resident was seen reading without them. The resident's spouse confirmed the glasses were broken, and staff acknowledged the issue had persisted since at least December 2023. The Social Service Director was unaware of the problem until June 2024, when she found an unsigned note about the broken lens, and no vision appointments had been scheduled for the resident.
Failure to Maintain Safe Environment Leads to Resident Falls
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents, leading to multiple incidents of falls. Resident 51, who was cognitively intact and diagnosed with cancer, experienced an unwitnessed fall due to a mattress that did not fit the bed frame properly. Despite interventions to prevent future falls, such as applying nonslip material and adjusting the mattress, these measures were not implemented. The mattress was observed to be too large for the bed frame, positioned on top of the brackets instead of within them, and lacking the nonslip material, which contributed to the resident's fall. Resident 57, with a history of stroke and moderate cognitive impairment, was at risk for falls due to impulsive behavior and poor safety awareness. Despite a care plan that included interventions like keeping a bedside commode nearby and ensuring the call light was within reach, these measures were not consistently followed. The resident was observed attempting to transfer without assistance, leading to a fall. Additionally, the resident was found wearing regular socks instead of nonskid socks, which was identified as a contributing factor to the fall. Resident 63, who required a bedside commode for toileting, experienced multiple falls while attempting to self-transfer in the bathroom. The absence of a bedside commode in the resident's room, as noted in the care plan, was confirmed by staff, indicating a failure to adhere to the care plan and contributing to the resident's falls.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to ensure that nutritional supplements were provided to a resident, which placed them at risk for weight loss. The resident, who was admitted in 2018 with a diagnosis of diabetes, was supposed to receive a diabetic nutritional supplement twice daily as indicated in a nutritional screen dated February 1, 2024. However, after being hospitalized in April 2024 and returning to the facility on April 16, 2024, the resident's supplement was not restarted. This oversight was acknowledged by a Licensed Practical Nurse (LPN) Resident Care Manager on June 13, 2024, who confirmed that the supplement was not resumed upon the resident's readmission.
Failure to Obtain Oxygen Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with cancer, as evidenced by the lack of physician orders for oxygen and the unsanitary condition of the resident's oxygen equipment. The resident was observed using a nasal cannula connected to an oxygen concentrator, which had a thick layer of dust on its vent, indicating it had not been cleaned for a long time. Staff confirmed that the equipment should be cleaned weekly and that a nurse could initiate oxygen use but needed to obtain a physician's order for its continued use. However, the resident's clinical record did not contain any such orders, as verified by the Director of Nursing Services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, leading to a deficiency in care. The resident, admitted in 2017, was assessed with moderately impaired cognition and PTSD. The facility's care plan for the resident included general interventions such as approaching in a non-threatening manner and avoiding forced care. However, the care plan lacked individualized interventions to address specific triggers that could re-traumatize the resident. Interviews with staff revealed that they were unaware of specific PTSD-related behaviors or triggers for the resident, and the facility had not assessed or care planned for these individual needs. The deficiency was further highlighted by the lack of documentation in the resident's health record regarding the development and implementation of personalized interventions for trauma triggers. Staff members, including the Social Service Director and the Administrator, acknowledged the necessity of identifying triggers for residents with PTSD to prevent re-traumatization. Despite this acknowledgment, the facility did not have a resident-centered care plan that addressed the unique needs of the resident, placing them at risk for re-traumatization and a decrease in their quality of life.
Infection Control Breach on 200 Hall
Penalty
Summary
The facility failed to adhere to infection control standards on the 200 hall, as observed during a survey. A CNA, identified as Staff 37, was seen carrying dirty linens down the hall without placing them in a bag, which is against the facility's infection control protocol. This action was acknowledged by Staff 37, who admitted to not having bags in her pocket and being aware of the requirement to bag linens before transport. During an interview, the Administrator, DNS, and Regional Director of Clinical confirmed that the expectation for staff is to place dirty linen in a bag for transport from the resident room to the soiled linen room.
Antibiotic Administration Without Indication
Penalty
Summary
The facility failed to ensure that a resident was not administered an antibiotic without proper indication, which was identified during a review of three sampled residents for urinary tract infections (UTIs). Resident 86, who was admitted in 2023 with a diagnosis of UTI, experienced increased confusion on October 7, 2023, leading to a hospital evaluation and return on October 8, 2023. A urine culture from October 7, 2023, showed mixed growth of skin and genital organisms, indicating an improper collection and suggesting that a new sample should be submitted if clinically indicated. Despite this, the resident was administered antibiotics from October 10 to October 16, 2023, for a UTI. The facility's policy required a 72-hour review of test results after starting antibiotics to ensure their necessity, but no such review was documented for Resident 86, and the urine analysis results did not support the administration of antibiotics.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of a fall, which was a deficiency identified during the survey. Resident 89, who was admitted to the facility with a fractured leg and pelvis, experienced an unwitnessed fall out of bed shortly after admission. The resident had a BIMS score indicating moderate cognitive impairment. Despite the fall occurring on 12/23/22, the resident's emergency contact, identified as Witness 1, was not informed by the facility staff about the incident. Witness 1 only learned of the fall through the resident and expressed upset over not being notified by the facility. Staff 21, an LPN, confirmed the lack of notification, and Staff 2, the DNS, acknowledged that Witness 1 should have been informed as the emergency contact.
Failure to Report and Investigate Resident Altercations and Abuse Allegations
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving two residents, one of whom was cognitively impaired and the other with a history of aggressive behavior due to a head injury. Despite multiple staff members recalling the incident where the aggressive resident hit the cognitively impaired resident, there was no documentation or update to the care plans to prevent recurrence. The incident was not reported to the management team, and no incident report was filed, leaving the residents at risk for ongoing abuse. Additionally, the facility did not adequately investigate or report an allegation of abuse involving another resident who claimed to have been pushed by a CNA, causing pain. The grievance was documented, but the investigation was incomplete, as there was no evidence that the allegation of physical abuse was addressed. The facility's administrator acknowledged the lack of evidence for a proper investigation or reporting to the state, indicating a failure in handling the abuse allegation appropriately.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan for two residents within 48 hours of admission, as required. Resident 134, admitted with a diagnosis of kidney disease, was scheduled for dialysis three times a week. However, the baseline care plan did not include information about the dialysis schedule or the type and location of the dialysis access, despite these details being present in the admission orders. Staff 30, an LPN Resident Care Manager, acknowledged that the baseline care plan for dialysis was not initiated. Resident 335, admitted with a left femur fracture and dementia, was prescribed psychotropic medications. Despite having severe cognitive impairment and being at high risk for falls, the baseline care plan did not address these issues. Multiple staff members, including CNAs and the Director of Rehabilitation, were unaware of Resident 335's fall risk and cognitive impairments. Staff 27 and Staff 30, both LPN Unit Managers, confirmed that the baseline care plan should have included fall risk, psychotropic medications, and dementia diagnosis but was not completed within the required timeframe.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure the availability of pain medications for two residents, leading to increased pain levels. Resident 85, admitted with arm and leg fractures, was prescribed oxycodone every four hours while awake. However, from November 24 to November 27, 2023, the medication was not administered six times. Subsequently, Percocet was prescribed but was unavailable. No alternative pain relief medications were provided, resulting in Resident 85 experiencing moderate to severe pain levels ranging from four to nine. Despite being aware of the resident's pain and upcoming surgery, staff did not address the medication shortage, and no documentation was provided to show additional pain management measures were implemented. Resident 339, admitted with a left femur fracture, did not receive any pain medication from the time of admission until the morning of June 14, 2024, despite requesting it multiple times. The resident's family member confirmed the lack of pain medication, and a CNA reported informing the nurse of the resident's request. The Director of Nursing Services (DNS) acknowledged that the emergency medication kit contained the necessary pain medications and that all nurses had access to it, indicating a failure in administering the medication as needed.
Failure to Transport Resident to Dialysis
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of kidney disease was transported to dialysis, as required by hospital orders. The resident was admitted to the facility in 2023 and was scheduled to receive dialysis treatments on Mondays, Wednesdays, and Fridays. On December 11, 2023, the resident missed a dialysis treatment due to the facility's failure to arrange transportation to the dialysis center. This was confirmed by a former RN, Staff 43, who reported the incident to the State Survey Agency, and by Witness 10, a Dialysis RN, who verified the missed treatment was due to lack of transportation. Despite being aware of the resident's need for transportation, the facility did not follow through with the necessary arrangements, as indicated by Staff 2 (DNS) via email, who provided no additional rationale for the missed appointment.
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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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