Mt. Tabor Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6040 Se Belmont Street, Portland, Oregon 97215
- CMS Provider Number
- 385141
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mt. Tabor Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with acute kidney failure and dependence on renal dialysis had a care plan specifying thrice-weekly dialysis with arranged transportation, but the facility failed to schedule transportation over a holiday period, leading to missed treatments and lack of documentation for one scheduled session. The receptionist reported being unable to set up transportation, and an LPN confirmed that staff knew transportation needed to be scheduled but the resident still missed a treatment. A family member was contacted by the dialysis center about the resident’s absence, found the resident very sick, and requested transfer to the ER, where dialysis was subsequently completed. The DNS acknowledged that the missed dialysis occurred because transportation had not been scheduled.
A resident with a feeding tube did not receive scheduled tube feeding on time due to an LPN's lack of competency in tube feeding administration. The LPN and Interim DNS were both unsure how to properly connect the feeding tube, and attempts to resolve the issue with assistance from another LPN were unsuccessful due to incompatible connectors. This resulted in a significant delay in the resident's care, and it was determined that the LPN required additional training.
A resident with moderate cognitive impairment and at risk for malnutrition did not receive a physician-ordered dietary supplement for nearly two weeks. The supplement was not available, and although nursing staff contacted the pharmacy, it was not delivered, and follow-up actions were unclear.
A resident with a history of GERD and a choledochoduodenal fistula did not receive tube feeding care as ordered, including receiving water flushes at a higher rate than prescribed and being given an incorrect tube feeding formula without proper authorization. These errors were confirmed by staff interviews and led to the resident experiencing vomiting and increased digestive symptoms.
Staff did not follow Enhanced Barrier Precautions when handling a resident's feeding tube. Despite signage indicating the need for these precautions, an Interim DNS and an LPN were observed wearing only gloves, without gowns, while providing care to a resident with a gastric tube and GERD.
An agency LPN failed to administer prescribed medications and treatments to seven residents with conditions such as GERD, hypothyroidism, Parkinson's Disease, and pain, as documented in the MARs. The DNS confirmed the omissions and attempts to contact the LPN were unsuccessful.
The facility did not maintain an accessible grievance process, as residents and their representatives were unaware of how to file grievances, and forms were not readily available or visible in common areas. Staff interviews confirmed that grievance forms were only provided upon request at nursing stations, and there was no way for residents to submit grievances anonymously. This resulted in very few grievances being filed over a two-year period and left concerns unreported and unresolved.
Four residents, including individuals with dementia, chronic kidney disease, cardiovascular surgery aftercare, and heart failure, did not have their required MDS assessments completed within mandated timeframes. Facility staff, including the DNS and RNCM, confirmed the delays and acknowledged ongoing difficulties in meeting assessment deadlines.
Surveyors found improper food storage, unsanitary kitchen and unit refrigerators, and staff not following beard net requirements. Food items were kept beyond policy limits or left undated and unlabeled, and a dirty fan was used near clean dishware, all contributing to unsanitary conditions.
A resident's right to personal property was not respected when staff confiscated the individual's phone after an accusation of viewing illegal content, following police involvement. The phone was locked away without a formal investigation, despite the resident being cognitively intact and expressing a desire to have the phone returned. Staff provided alternative means of communication, but some were unaware the phone had not been returned, and leadership acknowledged the resident's right to the device.
A resident with a history of stroke was allowed to keep Tylenol and Melatonin at the bedside for self-administration without a documented assessment of their ability to do so safely and without secure storage, contrary to facility policy. Staff interviews confirmed that the required assessment and provision of a lockbox were not completed after a physician's order was obtained.
Multiple deficiencies were observed in the facility's physical environment, including a resident room wall in disrepair, buckled carpet creating tripping hazards in a high-traffic area, and a resident's window that was unsecured and lacked a screen. The Maintenance Director was unaware of some issues and confirmed there was no system in place to routinely check or repair windows for safety.
A resident was coded as having schizophrenia on both admission and quarterly MDS assessments, despite the Director of Nursing Services confirming there was no supporting evidence for this diagnosis in the medical record. This led to an inaccurate assessment of the resident's mental health status.
A resident with dementia and diabetes, who had a history of multiple falls, did not have care plan interventions for fall prevention consistently implemented. Observations showed the room door was not kept open for visibility, and the resident's wheelchair and cane were not placed near the bed as required. Staff confirmed these interventions were not followed, increasing the risk of injury.
An agency LPN was absent from her assigned shift, spending most of the night in her car and failing to administer ordered and PRN medications or treatments to seven residents. Other staff confirmed the LPN's absence and the resulting missed care, with the incident verified through interviews and record reviews.
The facility failed to protect a resident from sexual abuse by another resident with a known history of inappropriate sexual behaviors. Despite staff awareness of the behaviors, the incident was not promptly reported or addressed, leading to the resident feeling uncomfortable and unsafe.
The facility failed to timely report allegations of abuse involving two residents. One resident masturbated in front of another during a movie, and the incident was not reported to the State Agency within the required two-hour timeframe. Multiple staff members were aware but did not take immediate action.
Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
The facility failed to provide transportation for a resident requiring scheduled dialysis treatments, resulting in missed dialysis sessions. The resident was admitted with diagnoses including acute kidney failure, dependence on renal dialysis, and metabolic encephalopathy. The resident’s care plan dated 11/22/25 documented that dialysis was to occur three days a week on Tuesday, Thursday, and Saturday, with transportation to the dialysis center to be provided and the resident to remain free from complications secondary to requiring dialysis. Progress notes showed the resident received dialysis at the hospital on 12/24/25 and did not receive treatment on 12/25/25, and there was no documentation of dialysis treatment on 12/27/25. In interviews, the receptionist stated that she or nursing staff assist with dialysis transportation planning and reported she was unable to set up the resident’s dialysis transportation over the December holiday. A family member reported receiving a call from the dialysis center asking why the resident was not present for dialysis and stated the resident was very sick and had not been admitted in that condition. The family member went to the facility and requested that staff send the resident to the ER for dialysis, which was completed on 12/29/25. An LPN stated that evening shift staff had informed her that the resident’s transportation to dialysis needed to be scheduled and confirmed the resident missed the dialysis treatment that was supposed to occur on 12/27/25. The DNS acknowledged that the resident missed dialysis due to transportation not being scheduled.
Lack of Competency in Tube Feeding Administration Delays Resident Care
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies to care for a resident with a feeding tube. A resident with a history of Gastroesophageal Reflux Disease (GERD) and choledochoduodenal fistula was admitted with physician orders for scheduled tube feedings. On the scheduled day, an LPN was observed to have difficulty identifying and managing the resident's feeding tube due to a missing connector. The LPN left the room to seek assistance after expressing uncertainty about the correct connection method. The Interim Director of Nursing Services (DNS) also entered the room but was similarly unsure about the appropriate procedure for the feeding tube. Multiple staff members, including the MDS Coordinator, were involved in attempts to resolve the issue, but compatible connectors were not immediately available. As a result, the resident's tube feeding was delayed by two and a half hours. Staff interviews and record reviews revealed that the LPN had not received adequate training in tube feeding administration and required further orientation, as indicated by a skills checklist completed after the incident.
Failure to Administer Prescribed Dietary Supplement as Ordered
Penalty
Summary
A resident admitted with a diagnosis including a gallbladder fistula and identified as being at risk for weight loss and/or malnutrition was not administered a prescribed dietary supplement, Phos-Nak, as ordered by the physician. The care plan required encouraging the resident to eat, consulting with the Registered Dietitian, and following a therapeutic diet, including the administration of Phos-Nak three times daily with meals and at bedtime. Medication administration records showed that the supplement was not given for a period of nearly two weeks, with progress notes indicating the medication was unavailable and on order from the pharmacy. Nursing staff reported contacting the pharmacy to request the supplement, but it was not received, and there was uncertainty regarding follow-up actions by the responsible care manager.
Failure to Follow Tube Feeding Orders and Formula Administration
Penalty
Summary
A deficiency occurred when a resident with a history of GERD and choledochoduodenal fistula, who required tube feeding, did not receive care and services as ordered. The resident's physician orders specified administration of free water via feeding tube at 35 ml/hr for 18 hours per day and enteral feeding with Peptamen AF for the same duration. However, staff administered water flushes at 100 ml/hr instead of the ordered rate, and the resident subsequently experienced a large emesis. The provider was notified, tube feeding was held, and the resident was sent to the emergency department due to ongoing vomiting and concerns about altered electrolytes from the excess water. Additionally, staff ran out of the prescribed Peptamen AF formula and administered Peptamen 1.5 without a physician order or approval from the registered dietician or the initiating team. The resident reported increased digestive symptoms after receiving the incorrect formula. Staff interviews confirmed the errors in both the water flush rate and the tube feeding formula administration.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
Facility staff failed to adhere to Enhanced Barrier Precautions during the care of a resident with a gastric tube. The resident, admitted with diagnoses including GERD and the presence of a gastric tube, required Enhanced Barrier Precautions as indicated by signage outside the room. On two separate occasions, staff members, including the Interim Director of Nursing Services and an LPN, were observed handling the resident's feeding tube and assessing the pump and gastric tube while wearing only gloves and not donning a gown as required. The Interim DNS later acknowledged that neither she nor the LPN wore a gown when accessing the resident's gastric tube.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Staff 17, a former agency LPN, failed to administer prescribed medications and treatments according to physician orders for seven sampled residents. The missed medications included Omeprazole Suspension and water flushes for a resident with esophageal reflux and cerebral palsy, Pantoprazole Sodium for a resident with chronic gastritis and GERD, and Levothyroxine for several residents with hypothyroidism. Additionally, Carbidopa-Levodopa for Parkinson's Disease and Oxycodone for pain were not administered as ordered. These omissions were documented in the Medication Administration Records (MARs) for the affected residents on the specified date. The Director of Nursing Services (DNS) confirmed that Staff 17 did not administer the prescribed medications and treatments during her scheduled shift. The DNS stated that all physician orders are expected to be followed and that medications should be administered as ordered. The facility attempted to contact Staff 17 through the agency staffing company, but was unable to reach her, as two phone numbers were disconnected and the third went to a generic voicemail with no return call received. The residents involved had significant medical histories, including conditions such as esophageal reflux, cerebral palsy, chronic gastritis, hypothyroidism, Parkinson's Disease, and pain management needs. The failure to administer medications and treatments as ordered was confirmed through record review and staff interview, with the DNS acknowledging the lapses in medication administration for all seven residents on the specified date.
Failure to Provide Accessible Grievance Process
Penalty
Summary
The facility failed to ensure a system was in place to receive and resolve resident and/or resident representative grievances, as evidenced by a lack of accessible grievance forms and insufficient communication about the grievance process. Record review showed that only a handful of written grievances were completed by residents or family members over a two-year period, with no grievances filed for most of 2024 and only a few in 2025. During a Resident Council meeting, multiple residents reported they were unaware of the grievance process, did not know how to file a grievance, and felt that reporting concerns to staff was ineffective. Observations throughout the facility revealed no visible information on how to file grievances, submit them anonymously, or access grievance forms. Interviews with staff indicated that grievance forms were not routinely provided to residents and were only available at nursing stations upon request. The Grievance Officer confirmed that forms were not accessible unless given by staff, and the Administrator acknowledged that residents had no means to submit grievances anonymously. This lack of an accessible and transparent grievance process placed residents at risk for unreported and unresolved grievances.
Failure to Complete Timely Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for four out of eight sampled residents within the required timeframes. Specifically, one resident with dementia had an annual Minimum Data Set (MDS) assessment that was incomplete past the deadline, as confirmed by the Director of Nursing Services (DNS). Another resident, readmitted with chronic kidney disease and a history of transient ischemic attack, did not have an admission MDS completed within the required 14 days. The DNS acknowledged responsibility for this delay. Additionally, a resident admitted after cardiovascular surgery had an admission MDS that was not completed by the deadline, with the responsible Registered Nurse Case Manager (RNCM) confirming the assessment was late and noting ongoing struggles with timely completion. Another resident with acute chronic diastolic heart failure had an admission MDS completed one day late, also acknowledged by the RNCM. These delays in completing required assessments placed residents at risk for unidentified care needs.
Deficient Food Storage, Sanitation, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and sanitation practices within the facility. In the main kitchen refrigerator, tofu salad and chicken salad were stored for eight days, exceeding the facility's stated four-day discard policy, and two containers of lunch meat were found undated. Staff confirmed the salads were made on the date indicated and should have been discarded earlier. Additionally, staff members were seen in the kitchen without required beard nets, in violation of the facility's Employee Cleanliness Policy, which mandates facial hair be completely covered in food preparation areas. On a unit floor, the refrigerator was found with a spilled substance and crumbs, as well as undated and unlabeled food items, including a foiled item stuck to the bottom and a glass container with food. Staff interviews revealed confusion about responsibility for cleaning and monitoring the refrigerator, with some staff unsure who was accountable for these tasks. Furthermore, a fan covered in dark brown debris was observed blowing onto cleaned utensils and dishware in the dishwashing area, which was acknowledged by the Dietary Manager as inappropriate for the area.
Failure to Respect Resident's Right to Personal Property
Penalty
Summary
Facility staff failed to respect a resident's right to personal property when they confiscated the resident's phone following an accusation of viewing illegal pornography. The incident began when staff observed the resident using their phone and contacted the police, who reportedly instructed staff to take the phone and not return it. The phone was subsequently locked in the Resident Care Manager's office, and the resident, who was documented as cognitively intact, expressed a desire to have the phone returned. Multiple staff interviews confirmed that the phone remained locked away, and there was no formal investigation conducted after the incident. The resident was provided access to a cordless phone for calls and received assistance from staff and a friend to access the internet or obtain a phone without internet capabilities. Some staff were unaware that the resident's phone had not been returned, and facility leadership acknowledged the resident's right to possess their phone.
Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
A resident with a history of stroke resulting in left-sided hemiparesis and hemiplegia was observed to have unsecured medications, including Tylenol and Melatonin, on their bedside nightstand on multiple occasions. The resident had no significant cognitive impairment and had a physician's order allowing these medications to be kept at the bedside for self-administration. However, there was no documented assessment completed to determine the resident's ability to safely self-administer these medications, as required by facility policy. Interviews with staff revealed that the process for assessing the resident's capability to self-administer medications was not followed. The resident was not provided with a lockbox to secure the medications, and staff were unaware that the medications were being kept at the bedside. The lack of assessment and secure storage was confirmed by multiple staff members, including the LPN Care Manager and the Director of Nursing Services, who acknowledged that the required procedures were missed after the physician's order was obtained.
Failure to Maintain Safe and Homelike Physical Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies in the physical environment. Observations revealed that the wall to the right of a resident's bed was in disrepair, with scratches and missing paint, and the Maintenance Director was unaware of the issue until it was pointed out. The Administrator confirmed that all resident rooms were expected to be in good condition and properly maintained. Additionally, four sections of carpet, each approximately five feet long, were observed to be buckled up to four inches high in a high-traffic area on the third floor. The Maintenance Director acknowledged that these buckled carpets had been present for a significant amount of time and confirmed they posed tripping hazards, especially for residents with a shuffling gait. A resident admitted after cardiovascular surgery was found to have a bath towel draped over their window to prevent drafts, as the window could be detached and had no screen. The resident demonstrated that the window was not secure and stated it had been this way since admission. After a gust of wind dislodged the window and towel, the Maintenance Director screwed the window shut. The Maintenance Director later acknowledged that the window's arms had broken off and that the detachable window was a safety issue. He also stated there was no system in place to check or audit windows for safety and repair before or during a resident's stay.
Inaccurate MDS Assessment Due to Unsupported Mental Health Diagnosis
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments that accurately reflected a resident's mental health diagnoses. Specifically, a resident admitted with major depressive disorder and schizophrenia had schizophrenia coded in Section I of both the admission and quarterly MDS assessments. However, upon review, the Director of Nursing Services (DNS) confirmed there was no supporting evidence in the medical record for the diagnosis of schizophrenia, and acknowledged that the MDS should not have been coded with this diagnosis in the absence of documentation. This resulted in an inaccurate assessment for the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement fall prevention interventions for a resident with dementia and diabetes, who had a history of multiple falls. The resident's care plan included specific interventions such as keeping the room door open for visibility, ensuring the wheelchair was at the bedside, and placing the cane near the bed when the resident was in bed. However, observations revealed that the room door was often closed or only partially open, preventing staff from visualizing the resident. Additionally, the resident's wheelchair was repeatedly found across the room under the television, and the cane was placed next to the bathroom wall instead of near the bed. Staff interviews confirmed that the care plan interventions were not being followed. A CNA and an LPN both acknowledged that the wheelchair and cane should have been near the resident's bed for fall prevention, and the Director of Nursing Services confirmed that the interventions were not in place as directed. These failures to implement the care plan placed the resident at risk for injury due to inadequate supervision and lack of access to necessary mobility aids.
LPN Absence Results in Missed Medications and Treatments
Penalty
Summary
Staff 17, a former agency LPN, failed to adhere to professional standards for medication management and oversight of assigned residents during a night shift. According to interviews and record reviews, Staff 17 was absent from the facility for most of her shift, having slept in her car in the facility parking lot. As a result, seven residents missed their ordered medications and did not receive PRN medications or treatments as required. Staff 17 was found asleep in her car near the end of the shift and indicated she could not finish her duties. Other staff confirmed her absence and the resulting missed medication administration. The Director of Nursing Services (DNS) and other staff verified that Staff 17 was not present to fulfill her responsibilities, which included administering medications and treatments as ordered by providers. Attempts to contact Staff 17 after the incident were unsuccessful, as provided phone numbers were either disconnected or not answered. The investigation confirmed that the lack of licensed nurse oversight during the shift led to unmet medical needs for the affected residents.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, specifically involving Resident 201 and Resident 202. Resident 201, who was moderately cognitively impaired and had a history of socially inappropriate sexual behaviors, masturbated during a movie while sitting next to Resident 202. This incident made Resident 202, who was cognitively intact, feel uncomfortable and unsafe. Despite Resident 201's known history of such behaviors, appropriate measures were not taken to prevent this incident. Staff members were aware of Resident 201's inappropriate behaviors, including masturbating in common areas and exposing private parts, yet failed to adequately monitor or intervene. On the day of the incident, an activity staff member was present but not close enough to prevent or address the behavior. Additionally, there was a delay in reporting the incident, as it was not communicated to the appropriate personnel until two days later. Interviews with staff revealed a lack of immediate action and proper reporting. Staff 7, who was the charge nurse on the day of the incident, did not initiate an investigation or report the incident promptly. Staff 8 and Staff 6 were aware of the incident but did not ensure it was reported to the nurse in a timely manner. This lack of prompt reporting and intervention contributed to the failure to protect Resident 202 from sexual abuse by Resident 201.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Survey Agency for two residents. Resident 202, who was cognitively intact, and Resident 201, who was moderately cognitively impaired, were involved in an incident where Resident 201 masturbated in front of Resident 202 during a movie. Resident 202 reported the incident to a CNA the following day, but the CNA did not immediately escalate the report. The incident was eventually reported to the State Agency two days later, which was not within the required two-hour timeframe as per the facility's policy. Staff interviews revealed that multiple staff members were aware of the incident but did not take immediate action to report it. The charge nurse on duty at the time of the incident did not initiate an investigation or report the incident when she first heard about it. It was only after another CNA informed the RNCM two days later that the incident was formally reported to the State Agency. The facility's Administrator confirmed that the report was not submitted timely, as required by their policy.
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A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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