Marquis Centennial Post Acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 725 Se 202nd Avenue, Portland, Oregon 97233
- CMS Provider Number
- 385183
- Inspections on file
- 20
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Marquis Centennial Post Acute Rehab during CMS and state inspections, most recent first.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
Surveyors found widespread environmental deficiencies, including dirty and dusty fixtures, vents, and fans in common areas, as well as unkept and unsanitary shower rooms with mold-like substances, rust, and damaged fixtures. A resident with pneumonia expressed concerns about the shower room's cleanliness and safety, and another resident was bothered by scratches and missing paint in their room. Facility staff acknowledged these issues during the survey.
Staff failed to label and discard food items appropriately in a unit refrigerator, leaving undated and expired food present. Housekeeping staff were unaware of food storage policies, and scheduled cleaning was missed. In the kitchen, dietary aides stored an ice scoop directly in the ice and used it without gloves, contrary to expected procedures. These actions did not meet professional standards for food safety.
Staff did not follow infection control protocols for two residents, including not using PPE during wound care for a resident with a draining leg wound and allowing another resident's urinary catheter tubing to rest on the floor. These actions were inconsistent with facility policy and CDC guidelines for enhanced barrier precautions.
A resident with dysphagia and cognitive impairment was provided with thin liquids instead of the prescribed mildly thickened liquids due to the care plan not reflecting the physician's order. Multiple CNAs were unaware of the dietary requirement, and the RNCM confirmed the care plan omission, resulting in the resident receiving inappropriate fluids.
A resident with anxiety disorder and malnutrition reported a broken bed foot board that remained unrepaired for several days. Despite two CNAs being aware of the issue and attempting to reinsert the foot board, maintenance was not notified, and no repair request was submitted. The Maintenance Director stated staff are expected to report such issues electronically.
The facility failed to follow care plans and provide adequate supervision, resulting in falls and injuries for two residents. One resident sustained serious injuries after a CNA allowed them to walk to the bathroom with only a cane, contrary to their care plan. Another resident, with a history of falls, was left unsupervised while awake, leading to multiple falls.
The facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for a resident with dementia and emphysema, who had impaired memory and decision-making skills. The notice was given on the last covered day of Medicare Part A services instead of the required 48-hour notice, placing the resident at risk for unknown financial liabilities.
The facility failed to conduct a new and accurate Level I PASARR for a resident with serious mental illness diagnoses and did not complete a referral for a Level II PASARR. The resident exhibited significant behavioral issues, and the administrator acknowledged the incorrect coding and the need for a referral.
The facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. Staff were unaware of a communication binder available to assist in communication, leading to ineffective communication and unmet care needs.
The facility failed to follow physician orders for a resident with heart failure, missing multiple days of required daily weights in April 2024. Staff interviews confirmed that the resident rarely refused to be weighed, but documentation and communication lapses led to the deficiency.
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order, these assessments were not completed on multiple dates. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that required assessments were not performed or documented.
The facility failed to protect residents from physical abuse, involving multiple incidents where one resident pushed another, causing minor injuries, and another resident physically assaulted a fellow resident in the dining room. Additionally, a resident with severe cognitive impairment punched another resident in the face while she/he was resting in bed. Staff interviews confirmed a history of aggressive behavior and poor safety awareness among the involved residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including a lack of maintenance and cleanliness in common areas and resident spaces. In the dining room, all hanging light fixtures contained dead insects, portable fans were visibly dusty and blowing air toward residents, and floor vents were coated in thick dust, debris, and cobwebs. In the kitchen, a dirty floor fan was operating and blowing air across both clean and dirty areas, including sanitized food containers. A ceiling vent in a hallway was also found with significant dust and cobweb buildup. Facility staff, including the Administrator and Maintenance Director, acknowledged these concerns during the survey. A resident with a recent admission for pneumonia reported concerns about the cleanliness and safety of the shower room, specifically noting a black substance on the floor that staff attempted to clean without success. Observations confirmed the shower room was unkept, with mold-like substances, rust, peeling tiles, a loose drain lid, and a dirty fan. Clean linens were stored on a rusty shelf, and the water handle was loose and difficult to adjust. Another resident's room was observed with scratches and missing paint on the wall, which the resident found bothersome. Staff acknowledged these environmental issues required attention.
Improper Food Labeling and Unsafe Ice Handling Practices
Penalty
Summary
Facility staff failed to ensure proper labeling and timely disposal of food items in one of two unit refrigerators. Observations revealed several undated containers of food, including a meal with a ticket dated ten days prior, and other containers of spaghetti and rice with mixed vegetables that were not labeled. Interviews with staff indicated that housekeeping was responsible for cleaning and discarding old or undated food items every 72 hours, but the designated housekeeper was away, and the last cleaning had occurred a week prior. Housekeeping staff were unaware of the facility's food storage policies, and maintenance staff confirmed the cleaning schedule was not followed as expected. Additionally, during a kitchen tour and meal service observation, a covered container of ice was found with the ice scoop stored inside, directly on the ice. Dietary aides were observed using the scoop without gloves and returning it to the ice container after use. Staff interviews revealed a lack of awareness of proper procedures for storing the ice scoop, and the dietary manager confirmed that staff were expected to store the scoop separately from the ice. These practices did not align with professional standards for safe food storage and handling.
Failure to Implement Infection Control Practices for Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents with specific care needs. For one resident with a facility-acquired wound behind the left calf, staff did not follow enhanced barrier precautions (EBP) as required by facility policy and CDC guidelines. Despite the presence of a wound with fluid and drainage, staff did not don personal protective equipment (PPE) during high-contact activities such as bathing and wound care. Additionally, there were no signs posted outside the resident's room to indicate the need for EBP, and multiple staff members stated they did not use PPE because they believed the wound was not infected or the drainage was minimal. For another resident with an indwelling urinary catheter, the catheter tubing was repeatedly observed on the floor while the resident was in the activity room. Staff members acknowledged that the tubing should not touch the floor and confirmed the observation, but failed to ensure proper catheter care practices were followed. These lapses in infection control placed both residents at increased risk for infection.
Failure to Implement Physician Order for Thickened Liquids
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for mildly thickened liquids for a resident with dysphagia. The resident, who was cognitively impaired and required mildly thickened liquids per hospital discharge orders, did not have this requirement reflected in the nutrition care plan. Multiple observations showed the resident had access to thin liquids at the bedside, and several CNAs confirmed they were unaware of the thickened liquid order. The RN Case Manager acknowledged that the care plan did not include the physician's order, which led to staff providing thin liquids instead of the prescribed consistency.
Failure to Repair Broken Bed Foot Board
Penalty
Summary
A deficiency was identified when a resident, admitted with generalized anxiety disorder and malnutrition and noted to be cognitively intact, reported that the foot board of their bed was broken and had not been repaired. The issue was first noticed by the resident, who stated the foot board had been broken for several days. Observations confirmed that the foot board was unsecured and could be dislodged when pressure was applied. Two nursing assistants were aware of the broken foot board, having observed it was not secured and attempting to reinsert it, but neither notified maintenance. A review of maintenance work orders showed no request had been submitted for repair, and the Maintenance Director confirmed that staff were expected to report such issues electronically during their shift.
Failure to Follow Care Plans and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure staff followed the care plan related to fall safety and provide sufficient supervision to prevent a fall for two residents. Resident 306, who was admitted with a right leg fracture and right shoulder fracture, required extensive assistance from two or more staff to transfer on and off the toilet. However, on 5/7/23, an agency CNA responded alone to Resident 306's call for assistance and allowed the resident to walk to the bathroom with only a cane, contrary to the care plan. This resulted in Resident 306 falling and sustaining serious injuries, including a left shoulder fracture, a rib fracture, and a periprosthetic fracture involving the left greater trochanter. The facility's internal investigation confirmed that the CNA did not follow the care plan at the time of the fall. Resident 47, admitted with dementia and a history of falls, was also not provided with adequate supervision. The resident's care plan indicated that they should not be left unsupervised in their room while awake due to the risk of self-transfer attempts. Despite this, the resident experienced multiple falls, including one on 4/13/24, where the CNA failed to provide necessary details about care provided prior to the fall. Additionally, on 4/30/24, a CNA left Resident 47 alone in their room while awake, leading to the resident attempting to transfer themselves out of bed. The pressure-sensitive call light did not activate, and the resident was found attempting to stand up independently. Both incidents highlight a failure to adhere to care plans and provide adequate supervision, resulting in falls and injuries. Staff interviews revealed that CNAs were expected to consult care plans and perform frequent checks on high-risk residents, but these protocols were not consistently followed. The deficiencies in supervision and adherence to care plans directly contributed to the accidents involving Residents 306 and 47.
Failure to Provide Timely SNF ABN Notice
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely manner for a resident reviewed for Beneficiary Protection Notification. The resident, who was admitted with diagnoses including dementia and emphysema, had impaired short- and long-term memory and moderately impaired decision-making skills. The resident's last covered day of Medicare Part A services was on 4/1/24, and the facility provided the Notice of Medicare Non-Coverage on the same day. However, the facility should have given a 48-hour notice to inform the resident of the change, as stated by the Administrator. This failure placed the resident at risk for unknown financial liabilities.
Failure to Conduct Accurate PASARR and Referral for Behavioral Services
Penalty
Summary
The facility failed to conduct a new and accurate Level I PASARR when it became aware of indicators of a serious mental illness diagnosis for a resident. The resident, who was admitted in June 2023, had multiple diagnoses including Psychotic Disorder with delusions, Delusional Disorder, Dementia with behaviors, PTSD, Major Depressive Disorder, and anxiety. Despite these diagnoses and documented behavioral concerns such as delusions, physical and verbal aggression, socially inappropriate behaviors, and a history of suicidal behavior, the facility did not complete a correct Level I PASARR or make a referral for a Level II PASARR for behavioral services. Observations and record reviews revealed that the resident exhibited significant behavioral issues, including slamming doors, yelling at others, and making negative statements on multiple occasions. The resident was also observed to self-isolate in their room. The facility's administrator acknowledged that the Level I PASARR was coded incorrectly and that a referral for a Level II PASARR should have been initiated given the resident's diagnoses and behaviors. No additional information was provided to rectify the situation.
Failure to Develop Comprehensive Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. The resident, who primarily spoke Chinese/Taiwanese/Cantonese, was observed struggling to communicate with staff, who were unaware of the available communication aids. Specifically, a CNA was seen attempting to understand the resident through trial and error, and was unaware of a communication binder with pictures that could assist in communication. This binder was found in the resident's room but was not included in the care plan, leading to ineffective communication and unmet care needs. Further interviews revealed that the staff, including the CNA and RNCM, were not informed about the communication binder, and it was not documented in the resident's care plan. The SSD and Administrator both confirmed that communication aides should be included in care plans to ensure staff are aware of and use them. The lack of inclusion of the communication binder in the care plan resulted in staff being unaware of its existence and not utilizing it to aid in communication with the resident.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with heart failure, who was admitted in June 2023. The physician's orders required daily weights to be obtained for the resident and to notify the physician if the resident gained three pounds in 24 hours or five pounds in a week. However, a review of the resident's weight summary for April 2024 revealed multiple days without recorded weights, specifically on 4/2, 4/3, 4/4, 4/5, 4/8, 4/9, 4/12, 4/17, 4/18, 4/19, 4/20, 4/26, and 4/30. This failure to document weights as ordered placed the resident at risk for unmet needs related to their heart failure condition. Interviews with staff confirmed the deficiency. A CNA stated that the resident was to be weighed daily and rarely refused. An LPN confirmed that the resident was weighed daily due to heart failure and that nurses were expected to document reasons for any missed weights in the resident's progress notes. However, the LPN acknowledged that CNAs did not always inform her when weights were not obtained, leading to missing documentation. The Director of Nursing Services also confirmed that the resident was cooperative with being weighed and that nurses were expected to notify the physician if weights were not obtained, which did not occur as required.
Failure to Perform Post-Dialysis Assessments
Penalty
Summary
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order requiring nursing staff to assess the resident's vital signs and write a progress note upon their return from dialysis, these assessments were not completed on multiple dates in April 2024. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that post-dialysis assessments, which should include checking respiratory rate, heart rate, blood pressure, and the port site, were not performed or documented as required.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse by another resident, affecting two of the five sampled residents. Resident 34, who was admitted with a history of traumatic brain injury and severe cognitive impairment, was involved in multiple incidents with Resident 47, who had dementia with psychotic disturbance and PTSD. On one occasion, Resident 47 pushed Resident 34, causing her/him to fall and sustain minor injuries. Despite staff efforts to keep the residents apart, Resident 34 went outside to the courtyard where Resident 47 was visiting with her/his spouse, leading to the altercation. Staff interviews confirmed that Resident 47 had a history of aggressive behavior and poor safety awareness, which contributed to the incident. In another incident, Resident 47 physically assaulted Resident 34 in the dining room by grabbing her/him around the neck and face. This occurred after Resident 47 accused Resident 34 of being a thief, possibly confusing the voice on the television for Resident 34. Staff members intervened immediately, but Resident 34 sustained red marks on her/his neck and forehead. Staff interviews revealed that Resident 47 had been in a bad mood that day and had a history of aggressive behavior towards other residents. Additionally, Resident 43, who had severe cognitive impairment, punched Resident 29 in the face while she/he was resting in bed. The facility was not aware of the incident until the following day when swelling and discoloration were observed on Resident 29's upper lip. Staff interviews and written statements confirmed that Resident 43 had a history of behavioral disturbances and that the incident was not immediately reported or addressed. The facility acknowledged the findings of the investigation and the failure to protect residents from abuse.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
