Hillside Heights Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1201 Mclean Blvd., Eugene, Oregon 97405
- CMS Provider Number
- 385046
- Inspections on file
- 24
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Hillside Heights Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes, polyneuropathy, and a left great toe wound did not receive ongoing, comprehensive wound assessments as required by facility guidelines. Initial documentation from a wound clinic and a Skin and Wound Evaluation recorded wound size, tissue types, and drainage, but omitted key assessment elements such as wound edges, swelling, temperature, pain, treatment type, and care goals. After a later clinic note documented regression of the toe wound and aggressive debridement, no further Skin and Wound Evaluations were found in the record. A complaint was filed alleging the toe became infected due to negligence, and the resident reported continued pain. An LPN stated she performed wound care before discharge and noted only dried blood and blanchable redness, while the DNS acknowledged that, following the loss of a dedicated wound nurse, it was difficult for staff to complete the expected weekly wound assessments.
A resident with obstructive and reflux uropathy and a suprapubic catheter had physician orders for catheter changes every 30 days, but one scheduled change was placed on hold while staff awaited instructions due to a mistaken belief the resident had a penile implant, and there was no documentation that the catheter was changed. In a later month, the TAR showed an LPN documented completing a suprapubic catheter change without any supporting progress note, and the LPN later reported likely charting the treatment without performing it. The resident reported bladder pain and spasms and requested a urinalysis, the physician ordered the test, but the record showed no evidence it was completed, while staff interviews revealed uncertainty about responsibility for catheter changes and acknowledgment by the DNS that staff focused on the resident’s pneumonia instead of the ordered urinalysis.
The facility did not complete timely investigations for two residents: one who experienced an unwitnessed fall and another who was diagnosed with a sexually transmitted infection despite significant cognitive impairment. In both cases, required investigations into the incidents were either delayed or not documented, contrary to facility expectations.
A resident with a history of unsteadiness and traumatic brain injury experienced multiple falls, including one unwitnessed fall caused by malfunctioning bed brakes. Although the care plan included interventions for fall prevention, there was no documentation of required monthly bed brake checks or related maintenance work orders. Staff confirmed the brakes were not functioning at the time of the incident, and it was expected that staff check bed brakes before leaving the room.
A resident with dysphagia and dementia, who was care planned to need supervision or touch assistance with eating, was observed left alone with a meal tray and received no assistance during mealtime. Staff later removed the tray with most of the food uneaten, and confirmed they were aware of the resident's need for eating assistance but could not recall providing it.
A resident with a history of stroke and anxiety experienced delays in obtaining an ordered STI risk panel due to incomplete laboratory requisitions and issues with specimen collection. Despite urgent clinical symptoms and repeated attempts, the required testing was not completed, and the resident was eventually sent to the emergency department for further evaluation.
The facility failed to provide menus for residents to select their preferred meals, affecting their ability to make choices. Despite a change to a weekly menu system, residents reported not receiving these menus, leading to dissatisfaction and unmet preferences. Staff confirmed the change and the resulting resident dissatisfaction.
The facility's kitchen was found to have several sanitation and food storage deficiencies, including undated and improperly stored food items in the walk-in refrigerator and freezer, and a lack of temperature monitoring for a small refrigerator containing resident food items. The kitchen area also had unclean surfaces and floors, with food crumbs and debris present. Staff were unaware of temperature monitoring procedures, and the Dietary Manager acknowledged these issues.
An LPN at the facility failed to demonstrate appropriate competencies in infection control and insulin administration. The LPN did not clean the glucometer after CBG checks and did not prime the insulin pen as per manufacturer instructions. The LPN, new to the facility and in her first nursing job, was not aware of these procedures and had not undergone competency checks, as confirmed by the DNS.
The facility did not have an RN available for at least eight consecutive hours on three days, risking delayed nursing assessments for residents. This was confirmed through staff reports and acknowledged by the administrator.
The facility failed to maintain proper storage temperatures for a medication refrigerator, with temperatures reaching 73°F, affecting flu vaccines and insulin. Additionally, two open Tresiba insulin pens lacked open dates, and a treatment cart was left unlocked twice, risking unauthorized access. Staff acknowledged these issues.
The facility failed to ensure a homelike environment for residents, with issues such as a loud air conditioner, a burned-out bathroom light, peeling window paint, and a strong urine odor in a resident's room and wheelchair. Staff acknowledged these issues, but there was no documentation of corrective actions taken.
A resident prescribed Trazodone for insomnia did not receive information about the medication's risks and benefits, hindering informed decision-making. The resident, with a history of depression, anxiety, and insomnia, was unaware of any discussion or consent regarding the medication. An LPN confirmed the lack of documentation on this matter.
The facility failed to document advance directives for three residents, including one with depression and two with diabetes. The Director of Social Services confirmed the lack of documentation and was unable to provide evidence that advance directives were offered or reviewed with the residents or their families.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident's oxygen concentrator filters were not cleaned weekly as ordered, while another resident received oxygen at a higher rate than prescribed, with tubing not changed regularly, resulting in crusty debris. Staff confirmed the lack of documentation and absence of a facility policy for these tasks.
A facility failed to clean a community use CBG glucometer between resident uses, risking bloodborne illness. An LPN was observed not cleaning the glucometer after use and admitted to cleaning it only at shift start and end, without knowing the location of the required wipes. The DNS confirmed the expectation for cleaning with bleach wipes between uses, and a Corporate RN noted residents requiring regular and PRN CBG checks.
The facility failed to maintain essential kitchen equipment in safe operating condition, as the walk-in refrigerator's door handle was missing. Dietary staff acknowledged the issue, but the handle remained unrepaired during a follow-up visit. A dietitian noted the need to locate and reattach the handle.
Failure to Perform Ongoing Assessments for Diabetic Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing, comprehensive assessments and documentation for a non-pressure skin wound on a resident’s left great toe, as required by its Skin and Wound Management Guidelines. Those guidelines specified that neuropathic ulcers and vascular-related wounds required assessment, measurement, photography, and documentation in the Skin and Wound Module. The resident, admitted with an open wound of the left great toe and diabetes with polyneuropathy, had an admission MDS indicating a diabetic foot ulcer. A wound clinic note documented an incised blister on the left great toe with drainage and a wound surface area of 20 cm² or less. A subsequent Skin and Wound Evaluation recorded an “other wound” on the first digit of the left foot with specific length and width measurements, a wound bed containing epithelial, granulation, and slough tissue, and moderate serosanguineous drainage. However, this Skin and Wound Evaluation did not include required elements such as assessment of wound edges, swelling, temperature, pain, treatment type, or the care goal. A later wound clinic note indicated the left great toe wound had regressed and was aggressively debrided, with callus, fibrin, and slough removed, but there was no documented evidence of any further Skin and Wound Evaluations after that date. The state survey agency received a complaint alleging the resident developed an infected toe due to facility negligence, and the resident later confirmed the complaint and ongoing toe pain. An LPN reported performing wound care the day before discharge and recalled only slight dried blood and blanchable redness, with no black discoloration or signs of infection, and stated that weekly wound assessments were set to trigger automatically and typically completed by a wound nurse. The DNS stated he expected weekly skin and wound assessments but acknowledged the facility no longer had a wound nurse due to budget cuts, making it difficult for nurses to complete the weekly evaluations.
Failure to Provide Ordered Suprapubic Catheter Care and Urinalysis
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate suprapubic catheter care and to complete ordered diagnostic testing for a resident with obstructive and reflux uropathy. The resident was admitted with a suprapubic catheter and had physician orders on the Treatment Administration Record (TAR) for catheter changes every 30 days. In one month, the TAR entry was placed on hold with a note to see Administration Notes, which documented that the catheter was not changed while staff awaited special instructions from the in-house provider due to a presumed penile implant. There was no documentation that the catheter was changed that month. The following month, the TAR again indicated a 30‑day suprapubic catheter change, and the TAR showed that an LPN had completed the change on a specific date, but there was no corresponding progress note documenting that the procedure occurred. Subsequently, the resident reported bladder pain and spasms to an LPN and requested a urinalysis, believing there was an infection. The physician ordered a urinalysis, but the clinical record contained no documentation that the urinalysis was completed. Two public complaints were submitted to the State Survey agency stating that the resident’s suprapubic catheter had not been changed since admission and that the resident believed there was a urinary tract infection. During interviews, one LPN stated she was unsure whether the catheter should be changed at the facility or at a urology clinic and did not know if the catheter had been changed in the earlier month. Another LPN stated she did not recall ever changing the resident’s catheter and believed she likely documented completion of the suprapubic catheter change without actually performing it. The DNS acknowledged that documentation was lacking regarding follow‑through on the communication about a penile implant, that staff had mistaken the suprapubic catheter for an implant, and that staff focused on the resident’s pneumonia instead of the ordered urinalysis, resulting in the urinalysis not being performed and physician‑ordered treatment not being completed.
Failure to Timely Investigate Abuse Allegation and Resident Fall
Penalty
Summary
The facility failed to investigate a potential case of abuse and did not investigate a fall in a timely manner for two residents. One resident, admitted with unsteadiness on feet and a traumatic brain injury, experienced an unwitnessed fall while attempting to go outside. The investigation into this fall was not completed until nearly two weeks later, despite facility expectations that such investigations be completed within five days. Another resident, admitted with a history of stroke, anxiety, and significant cognitive impairment, was diagnosed with trichomonal vaginitis, a sexually transmitted infection, after presenting with persistent symptoms and being sent to the emergency department. Despite the diagnosis and a public complaint alleging a sexually transmitted disease, there was no documentation in the clinical record of an investigation into potential sexual abuse for this resident. Staff confirmed that an investigation into possible sexual abuse was expected but not completed.
Failure to Maintain Safe Environment Due to Malfunctioning Bed Brakes
Penalty
Summary
A deficiency occurred when the facility failed to maintain a safe environment free from accident hazards for a resident admitted with unsteadiness on feet and a traumatic brain injury. The resident experienced two falls on the day of admission, and a subsequent unwitnessed fall occurred when the resident rolled out of bed due to malfunctioning bed brakes. Although the baseline care plan included interventions such as a PT consultation and monitoring for changes in condition, the bed brakes in the resident's room were not functioning properly at the time of the fall. Maintenance staff stated that bed brakes were supposed to be checked monthly, but there was no documentation to verify these checks or any work orders related to the malfunctioning brakes during the relevant period. Nursing staff confirmed the bed brakes were not working at the time of the incident, and the DNS stated that staff were expected to check bed brakes before leaving a resident's room.
Failure to Provide Eating Assistance as Care Planned
Penalty
Summary
A resident with diagnoses of dysphagia and dementia, admitted in February 2025, was care planned to require supervision or touch assistance with eating due to an ADL self-care performance deficit. On observation, the resident was left alone in bed with a food tray and was unable to answer questions, with no staff present in the room. Staff later entered the room, asked if the resident was finished eating, and removed the tray despite approximately 90 percent of the food remaining. The staff member assigned to the resident confirmed knowledge of the care plan requiring one-person assistance and supervision for eating but could not recall if she had provided this assistance during the meal. The DNS confirmed that the staff working with the resident at the time did not know the resident and acknowledged the resident required assistance to eat.
Failure to Timely Process Physician Laboratory Orders
Penalty
Summary
The facility failed to process a physician's laboratory order in a timely manner for a resident admitted with a history of stroke and anxiety. A physician ordered a sexually transmitted infection (STI) risk panel, but the laboratory requisition was incomplete, lacking the necessary test code and name. The laboratory report indicated that no suitable specimen was received and requested clarification on test requirements. Despite the urgency noted on the requisition, the required Aptima swab was not provided, and the test was not performed. Subsequent clinical notes documented that the resident experienced ongoing symptoms, including foul-smelling vaginal discharge and new-onset hallucinations. The resident completed a course of antibiotics for a urinary tract infection (UTI) without improvement. Staff reported difficulties obtaining the required STI testing due to laboratory refusals and facility budget constraints. The Director of Nursing Services was unable to clarify what occurred with the laboratory results, and ultimately, the resident was sent to the emergency department for further evaluation.
Failure to Provide Menus for Resident Meal Preferences
Penalty
Summary
The facility failed to ensure a system was in place to honor resident food preferences, affecting four sampled residents. The deficiency was identified through observations, interviews, and record reviews. Residents, including those with diabetes and heart disease, reported not receiving menus to select their preferred meals. The facility had recently changed its menu system from providing daily menus to weekly menus distributed on Fridays. However, residents stated they did not receive these weekly menus, and staff confirmed that the change had upset several residents as it removed their ability to choose between meal options. Staff members, including CNAs and the dietitian, acknowledged the change in the menu system and the resulting dissatisfaction among residents. The facility's administrator stated that the change was discussed in Resident Council and at a food committee, but residents reported not being informed of these changes. The lack of menu distribution led to residents receiving meals without the opportunity to make choices, impacting their satisfaction and potentially their nutritional needs.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an inspection. In the walk-in refrigerator, there were several issues including an opened and undated plastic container with pickle spears, a cardboard box of dark brown bananas, and an open stick of margarine exposed to air and undated. The floor of the refrigerator was littered with food crumbs, brown splatters, and various small debris. Similarly, the walk-in freezer contained a bag of frozen tapioca hot dog buns with an expiration date of 12/22/22, and several opened and undated bags of frozen chicken strips, hamburger patties, and veggie vegan patties. A zip lock bag labeled pizza sausage was found to be freezer burnt with an illegible date. The freezer floor also had food crumbs and brown splatters of debris. In the main kitchen area, a wire rack next to a garbage can had metal containers with splatters of debris, and the bottom shelf of the steam table, where clean pots and pans were stored, had drips of white and brown debris. A wire shelf containing clean bowls was covered with a sticky brown film, and the floor throughout the main kitchen area was covered with food crumbs, brown splatters, and various small debris. Additionally, a small refrigerator containing juice, milk, and yogurt did not have a temperature log, and staff members were unaware of any temperature monitoring for this refrigerator. The Dietary Manager acknowledged these findings, indicating a lack of proper monitoring and maintenance of sanitary conditions in the kitchen.
LPN Lacks Competency in Infection Control and Insulin Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff 13, possessed the necessary competencies and skills for infection control during capillary blood glucose (CBG) checks and insulin administration. On the specified date, Staff 13 was observed obtaining a CBG for a resident and subsequently placing the glucometer in the treatment cart without cleaning it. Continuous observations revealed that Staff 13 administered medications and insulin to multiple residents without cleaning the glucometer. Staff 13, who had been working at the facility for one month and was in her first nursing job, stated that she cleaned the glucometers only at the beginning and end of her shift and was not aware of any competency checks by the facility. Additionally, Staff 13 did not follow the manufacturer's instructions for administering Novolog insulin, as she failed to prime the insulin pen with two units before drawing up the insulin for administration. When questioned, Staff 13 acknowledged her lack of knowledge regarding the need to prime the insulin pen and reiterated that she had not undergone competency checks. The Director of Nursing Services (DNS), identified as Staff 2, confirmed that nursing competencies had not been completed for Staff 13, highlighting a lapse in ensuring staff were adequately trained and competent in their duties.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day on three specific days within a 31-day period. This deficiency was identified through a review of the Direct Care Staff Daily Reports, which showed no RN coverage on the dates of August 20, 21, and 22, 2024. The absence of RN coverage on these days placed residents at risk for delayed nursing assessments. The facility's administrator acknowledged the lack of RN coverage on the identified dates during an interview conducted on August 29, 2024.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain proper storage temperatures for one of its medication storage refrigerators, as evidenced by temperature logs from August 2024. The logs indicated that the refrigerator on the East Hall exceeded the recommended temperature range of 36 to 46 degrees Fahrenheit on multiple occasions, reaching as high as 73 degrees Fahrenheit on August 21, 2024. This refrigerator contained flu vaccines and insulin, which require specific temperature conditions to maintain their efficacy. Staff 2, the Director of Nursing Services (DNS), acknowledged the temperature discrepancies during an observation on August 30, 2024. Additionally, the facility did not ensure proper labeling and security of treatment carts. On August 29, 2024, two open Tresiba insulin pens were found in the East Hall treatment cart without open dates, which was confirmed by an LPN. Furthermore, the same treatment cart was observed to be unlocked on two separate occasions, on August 26 and August 27, 2024, with residents and staff walking by. Staff 14, an LPN, admitted to leaving the cart unsecured both times, acknowledging that it should have been locked at all times to prevent unauthorized access to medications.
Facility Fails to Maintain Homelike Environment
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 19's room had an air conditioner unit that emitted a loud, high-pitched squeak, which was acknowledged by the facility's Administrator and Maintenance Director. Resident 6's bathroom light was burned out for about a week, despite being reported by a Nursing Assistant, and had not been fixed by the time of the survey. Additionally, Resident 27's room had a window with peeling paint and exposed particle board, and Resident 33's room had window trim pieces that were separated with exposed edges, both of which were acknowledged by the facility's staff. Resident 32's room and wheelchair were noted to have a strong odor of urine, which was acknowledged by multiple staff members, including CNAs, an LPN, and the Housekeeping staff. The resident was incontinent and wore multiple briefs and incontinent pads, contributing to the odor. Despite the night shift being responsible for cleaning wheelchairs, there was no documentation of the cleaning being done or of the resident refusing the cleaning. The facility's DNS and Corporate RN also acknowledged the persistent urine odor in the resident's room and wheelchair.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to provide risk and benefit information for a psychotropic medication to a resident, which was necessary for making informed decisions about their care. The resident, admitted in July 2022 with diagnoses of depression, anxiety, and insomnia, was prescribed Trazodone for insomnia as per a physician's order dated January 24, 2024. Upon review of the resident's medical record, there was no documentation indicating that the risks and benefits of Trazodone were discussed with the resident. During an interview on August 27, 2024, the resident stated they did not recall discussing the risks and benefits of the medication with facility staff or signing a consent form. On August 29, 2024, a Licensed Practical Nurse (LPN) Unit Manager confirmed the absence of evidence that the risks and benefits were reviewed with the resident.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document information related to advance directives and health care decisions for three of four sampled residents. Resident 17, admitted in July 2016 with a diagnosis of depression, had no evidence in their clinical record of being provided with information on the right to formulate an advance directive. This was confirmed by the Director of Social Services. Resident 34, admitted in June 2024 with a diagnosis of diabetes, also had no documentation indicating that an advance directive was offered or reviewed with the resident or their family. The Director of Social Services was unable to recall or provide documentation of this process. Similarly, Resident 37, admitted in July 2022 with a diagnosis of diabetes, had no documentation of an advance directive being offered or reviewed, and the Director of Social Services could not provide evidence of this having occurred.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 6, who was admitted in 2018 with chronic respiratory failure and hypoxia, had a physician order for weekly changes of the oxygen concentrator filter. However, observations on 8/27/24 revealed that the filters were dusty, indicating they had not been cleaned as required. Staff interviews confirmed that the responsibility for cleaning the filters was assigned to the evening nurse, but the task was not completed, as acknowledged by the Director of Nursing Services. Resident 10, admitted in 2014 with respiratory failure, was prescribed supplemental oxygen at 2 liters per minute to maintain oxygen levels above 90%. Observations from 8/26/24 to 8/29/24 showed the resident receiving oxygen at 3 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not changed weekly, resulting in crusty debris on the nasal cannula. Staff confirmed the lack of documentation for tubing changes and acknowledged the absence of a facility policy for cleaning or changing oxygen tubing, contributing to the oversight.
Failure to Clean Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of a community use CBG glucometer between resident uses, which placed residents at risk for bloodborne illness. During an observation, an LPN was seen obtaining a CBG for a resident and then placing the glucometer back in the treatment cart without cleaning it. The LPN continued to pass medication and administer insulin to multiple residents without cleaning the glucometer. The LPN stated that she cleaned the glucometers at the beginning and end of her shift with purple wipes, but did not know where the wipes were located, and they were not on the treatment cart. The Director of Nursing Services stated that the expectation was for staff to clean glucometers with bleach wipes between every use. A Corporate RN confirmed that there were residents on the hall who required regular and PRN CBG checks.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the walk-in refrigerator. On August 26, 2024, an observation revealed that the door handle to exit the refrigerator was missing. A dietary staff member stated that the handle had fallen off and was unsure of its whereabouts. The Dietary Manager acknowledged the issue and confirmed that the handle needed repair. A follow-up visit on August 28, 2024, showed that the door handle was still missing. On August 30, 2024, a dietitian mentioned that the staff needed to locate the handle and reattach it.
Latest citations in Oregon
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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