Myrtle Point Rehabilitation & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Myrtle Point, Oregon.
- Location
- 637 Ash Street, Myrtle Point, Oregon 97458
- CMS Provider Number
- 385254
- Inspections on file
- 20
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Myrtle Point Rehabilitation & Care during CMS and state inspections, most recent first.
A resident with a history of stroke, femur fracture, moderately impaired cognition, poor safety awareness, and a need for one-person assistance with toileting transfers was instructed by a CNA to urinate in their brief instead of being assisted to the bathroom or with a urinal in bed. An LPN had directed the CNA to assist the resident with a urinal, but another CNA reported hearing the resident call for help to use the bathroom and observed the CNA displaying anger toward the resident. The CNA later admitted yelling at the resident, citing the resident’s hearing impairment, and acknowledged telling the resident to urinate in the brief. The DNS stated the CNA admitted to inappropriate actions and confirmed it was unacceptable to instruct a resident to use a brief instead of providing toileting assistance.
Two residents, both found capable of consenting to sexual activity, were observed engaging in intimate acts in public areas due to the facility's lack of a designated private space for such encounters. Interviews confirmed that while private meetings were requested, only chaperoned interactions were permitted and no private area was provided.
Two residents, one with moderate cognitive impairment and another cognitively intact, were involved in intimate contact observed by staff. Despite the incident, staff did not promptly assess both individuals for their ability to consent or confirm the interaction was consensual, allowing them to remain together without proper evaluation.
A resident with chronic lung disease and moderate cognitive impairment was involved in an incident where another resident was observed with their hands up the first resident's shirt. The event was not reported to administration or the State agency within the required two-hour timeframe, with staff interviews revealing a lack of awareness of the reporting requirement.
The facility failed to employ a director of food and nutrition services with the required certification, risking unmet dietary needs for residents. The Dietary Manager stated she would be certified in February 2025, but no documentation was provided to confirm her current certification. The Administrator was informed of the lack of certification, which was also an issue in previous surveys. The Dietary Manager had not completed training due to her preceptor's passing.
The facility did not submit the required Payroll Based Journal staffing data for a specific quarter in 2024. The administrator was unaware of this omission until the survey team pointed it out, which risked inaccurate staffing data reporting.
The facility failed to ensure that nursing staff demonstrated competency in necessary skills and techniques, as evidenced by the absence of completed competency checklists for three CNAs. This deficiency was identified through interviews and record reviews, indicating inadequate record maintenance to confirm staff competencies, potentially risking poor quality of care for residents.
The facility failed to complete the required annual CNA training and performance reviews for two CNA staff members. The administrator could not provide documentation of the training or reviews, acknowledging that the records did not show the required 12 hours of in-service training. The facility was unable to access previous training records and had not started a new training service.
A facility failed to properly store and discard expired food items in a resident refrigerator, posing a risk of food-borne illness. An observation revealed expired applesauce, a sandwich, pineapple, and carrots, which the Dietary Manager confirmed should have been discarded.
The facility failed to maintain a clean and safe environment for residents, as evidenced by missing hearing aids for a resident with a stroke, a disrepaired window in another resident's room, and dirty sunroom windows obstructing views. Staff were unaware of the hearing aids' location, and maintenance issues were acknowledged but not promptly addressed.
A facility failed to protect residents from verbal abuse and neglect, as evidenced by a former administrator's aggressive behavior towards a resident and inadequate incontinence supplies for others. A resident reported emotional distress from the administrator's verbal abuse, corroborated by staff. Additionally, residents experienced discomfort due to incorrect-sized briefs and insufficient wipes, confirmed by staff and complaints. These deficiencies highlight significant care issues.
The facility failed to provide an ongoing activity program, as a resident expressed a desire to go fishing but was unable due to the facility van being not road legal. The van's registration was out of date, and the title was still in the previous owner's name. Additionally, a period without an Activity Director resulted in a lack of documented activities for several residents, with staff confirming that activities were not occurring despite an activity calendar being posted.
The facility failed to provide adequate staffing, resulting in unmet needs for residents. A resident with dementia was left without a required escort for a medical appointment due to short staffing. Multiple complaints and witness statements confirmed that the facility often operated below state minimum staffing levels, leading to delays in care and services for residents. Staff struggled to provide timely assistance, particularly during evening shifts.
A resident readmitted with MRSA was not placed on infection control precautions, as staff were unaware of the infection. The care plan showed precautions were delayed by 27 days, and a public complaint highlighted the issue alongside the removal of biohazard receptacles.
A resident with diabetes had cavities identified during a dental exam, with recommendations for treatment and a full crown. Despite a follow-up visit where X-rays couldn't be performed due to mental capacity, no referral to another dental provider was made. The facility administrator confirmed the lack of a dental referral setup.
Two residents experienced deficiencies in care at the facility. One resident, with hemiplegia and depression, was moved to a new room without necessary adaptive equipment for over two months. Another resident, with arthritis and intervertebral disc degeneration, used an ill-fitting power wheelchair and had inaccessible personal belongings due to staff inaction. These issues were compounded by a lack of follow-up on a new wheelchair prescription and inadequate unpacking assistance.
A resident, who was cognitively intact and diagnosed with arthritis and intervertebral disc degeneration, alleged emotional and psychological abuse by a former administrator after testing positive for COVID-19. The resident reported feeling bullied and uncomfortable speaking alone with the administrator, who was observed yelling and using an authoritative voice. Despite these allegations, the facility failed to report the incident to the State Survey Agency.
A resident who tested positive for COVID-19 reported feeling bullied and emotionally abused by a former administrator who instructed them to return to their room in an authoritative manner. Despite the resident's claims and corroboration from staff, the facility failed to document or conduct an investigation into the alleged abuse, placing residents at risk.
A resident with arthritis and intervertebral disc degeneration, who was cognitively intact, experienced a delay in receiving assistance with ADLs. The resident activated the call light, but two CNAs left without providing care due to the resident's request to keep quiet and not turn on the light. This resulted in the resident waiting in a soiled brief for 45 minutes to an hour. The facility's protocol for addressing such issues was not followed.
The facility failed to follow physician orders and respond to changes in condition for two residents. One resident did not receive prescribed Miralax for constipation in a timely manner, while another resident with dementia and a UTI showed signs of distress and was not promptly assessed by an LPN. Staff reported the LPN was unresponsive to the resident's needs, leading to potential risks for delayed treatment.
The facility failed to prevent accidents and monitor residents after falls, leading to incidents involving two residents with stroke diagnoses. One resident fell due to malfunctioning entrance doors and a ramp without railings, while another experienced multiple falls due to inadequate supervision and care plan updates. Neurological assessments were not documented after unwitnessed falls, and care plans did not reflect necessary interventions.
A resident with chronic pain did not receive Methadone as ordered due to pharmacy delivery delays and lack of physician notification, leading to unmanaged pain. The resident, who was cognitively intact, reported frequent medication delays, and witnesses confirmed the facility's consistent mismanagement of medications.
A resident with chronic pain experienced multiple missed doses of Methadone due to delays in delivery and waiting on physician orders, despite having a care plan for pain management. The resident, who was cognitively intact, reported frequent issues with late or missed medications, which was corroborated by witnesses. Facility staff acknowledged the resident's frequent absences but did not adequately address the medication management issues.
A resident's food preferences were not honored, leading to unmet needs. The resident reported dissatisfaction with meal schedules and choices, receiving disliked foods, and small portions. The alternative meal menu was removed and not reinstated, contributing to the resident's complaints.
The facility failed to maintain complete and accessible records for two residents, leading to the loss of TB testing records. A former administrator disposed of these records, requiring re-testing. One resident, admitted with blindness and dementia, had no documentation of TB testing prior to June 2024 and refused a test in August 2024. Another resident, with anxiety and dementia, had no prior TB testing documentation but received a test in August 2024. Staff confirmed the loss of records and the need for re-testing.
A resident with spinal stenosis experienced a three-month delay in receiving an MRI due to inaccurate documentation and lack of communication by the facility. The MRI order, issued in June, lacked a physician's signature and clear imaging instructions, leading to the delay until September. Despite multiple calls to update the order, the facility failed to act promptly, as acknowledged by the Social Service Director.
A resident with a history of aggression struck another resident, despite a care plan intervention to keep them at arm's length from others. The facility's investigation ruled out abuse but did not confirm adherence to the care plan, and there was no documentation of the incident in progress notes.
Failure to Maintain Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to maintain resident dignity when staff instructed a resident to urinate in their brief instead of providing toileting assistance. The resident had been admitted with a history of stroke and a fractured femur and, per a recent Significant Change MDS and CAAs, had moderately impaired cognition (BIMS score of 10), poor safety awareness, and required assistance from one staff member for toileting transfers. An alleged abuse report documented that an LPN directed a CNA to assist the resident with a urinal in bed, and that staff then instructed the resident to urinate in their brief because the resident continued to try to stand. In a written statement, the CNA acknowledged yelling at the resident, stating this was because the resident was hard of hearing, and admitted telling the resident to urinate in their brief. Another CNA reported hearing the resident yell for help to use the bathroom during the shift in question and reported to the LPN that the CNA was angry toward the resident. The CNA later stated she believed the resident was not medicated properly and required one-on-one care due to impulsiveness, and did not identify any issues between herself and the resident. The LPN stated she had told the CNA to be patient with the resident due to the CNA’s frustration and confirmed that the resident’s care was manageable with one staff member. When interviewed, the resident did not recall the incident. The DNS reported that the CNA had provided a statement admitting to inappropriate actions and acknowledged that it was unacceptable to instruct a resident to use their brief instead of providing toileting assistance, and that resident concerns should be addressed immediately.
Failure to Provide Private Environment for Consensual Intimacy
Penalty
Summary
The facility failed to provide a private environment for physical intimacy for two residents who were both determined to have the capacity and desire to engage in consensual sexual activity. One resident, admitted with chronic lung disease and moderate cognitive impairment, and another resident, admitted with heart disease and cognitively intact, were observed engaging in intimate acts in public areas both outside and inside the building. Staff documented incidents where the residents were seen with hands inside each other's clothing in non-private settings. Despite both residents being evaluated and found capable of consenting to sexual activity, interviews revealed that the facility did not provide a designated private space for residents to meet for intimacy. One resident reported that while meetings with the other resident were allowed, they were always chaperoned and no private area was made available. Facility staff confirmed that there was no location within the facility designated for private, consensual intimate encounters between residents.
Failure to Assess Resident for Sexual Consent After Intimate Incident
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for sexual consent following an incident involving intimate contact with another resident. One resident, who was moderately cognitively impaired and admitted with chronic lung disease, was involved in an incident where another resident, who was cognitively intact and admitted with heart disease, engaged in heavy petting and placed hands inside the first resident's shirt. Staff observed the incident and separated the residents, but did not immediately assess both individuals for their ability to consent to the interaction or confirm that the interaction was consensual. Staff interviews revealed that after the initial incident, both residents were allowed to remain together in a common area without a timely assessment of their ability to consent. The charge nurse acknowledged that he did not have the opportunity to speak to each resident separately to ensure consent until after a second event occurred. Documentation and staff statements confirmed that the required assessment for sexual consent was not conducted promptly after the incident, which constituted a failure to protect residents from potential abuse or trauma.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported within the required two-hour timeframe for one of four sampled residents. Specifically, a resident with chronic lung disease and moderate cognitive impairment was involved in an incident where another cognitively intact resident was observed with their hands up the first resident's shirt. This incident occurred at 8:30 PM but was not reported to the administrator until 9:30 AM the following day and subsequently to the State agency at 11:08 AM, resulting in a delay of over 12 hours from the time of the incident. Staff interviews revealed that the charge nurse was unaware of the two-hour reporting requirement, while the administrator confirmed that such allegations should be reported within two hours.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ a director of food and nutrition services with the required certification, which placed residents at risk for unmet dietary needs. During an interview, the Dietary Manager, identified as Staff 23, stated she would be certified as a dietary manager in February 2025. However, no documentation was provided to confirm her current certification status. The facility's Administrator, identified as Staff 1, was informed that Staff 23 lacked the required certification and had also not been certified in 2023, as identified during the annual recertification survey that year. Staff 1 mentioned that Staff 23 was working on the classes on Sundays but had not completed the training due to the passing of her preceptor. Staff 1 was unaware that the facility had been previously cited for the same issue in the 2022 and 2023 recertification surveys.
Failure to Submit Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to submit the required Payroll Based Journal staffing data for the third quarter of fiscal year 2024, covering the period from April 1, 2024, to June 30, 2024. This omission was discovered during a survey when the survey team alerted the facility's administrator to the missing data. The administrator, identified as Staff 1, stated that she was unaware of the failure to submit the data until informed by the survey team. This lack of submission placed residents at risk for inaccurate staffing data reporting.
Lack of Competency Documentation for CNAs
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in the skills and techniques necessary to care for residents, as evidenced by the lack of completed competency checklists for three certified nursing assistants (CNAs). During a review, it was found that the facility did not have the required documentation for Staff 18, Staff 26, and Staff 27, which was requested by the Administrator. This deficiency was identified through interviews and record reviews, indicating that the facility did not maintain adequate records to confirm the competencies of these staff members, potentially placing residents at risk for poor quality of care due to the lack of competent staff.
Failure to Complete Annual CNA Training and Performance Reviews
Penalty
Summary
The facility failed to ensure the required annual Certified Nursing Assistant (CNA) training and annual performance reviews were completed for two of the five sampled CNA staff members. This deficiency was identified during a survey when the administrator was unable to provide documentation of annual performance reviews and in-service training for the identified staff members. The administrator, who was recently hired, acknowledged that the records for the CNA staff did not show the required 12 hours of annual in-service training and did not include annual performance reviews. Additionally, the facility was unable to access previous internet-based training service records and had not yet started using a new internet-based training service.
Improper Food Storage and Expired Items in Resident Refrigerator
Penalty
Summary
The facility failed to ensure proper food storage and timely disposal of expired food items in a resident refrigerator, which was reviewed for food storage and handling. During an observation, it was found that the refrigerator contained several food items with expired dates, including applesauce expired for 7 days, a sandwich expired for 5 days, a dish of pineapple expired for 5 days, and a plastic bag of carrots expired for 4 days. This oversight was confirmed by the Dietary Manager, who acknowledged that the food items should have been discarded by their expiration dates.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment and ensure the safety of residents' belongings for two residents and one sunroom. Resident 18, admitted with a stroke, had hearing aids that were not located in her/his room, and staff were unaware of their whereabouts. Despite the issue being reported, no grievance was filed, and the interim Director of Nursing Services (DNS) was unable to provide additional information on the hearing aids' location. Resident 19, admitted with depression and respiratory failure, had a window in her/his room that was in disrepair, with glass improperly reinstalled and caution tape across it. The window was fastened with screws to prevent it from falling out, and maintenance staff acknowledged the need for repair. Additionally, the sunroom, where residents sat in wheelchairs to look outside, had cobwebs on the windows, obstructing the view. Residents expressed dissatisfaction with the dirty windows, and maintenance staff confirmed the need for cleaning. These deficiencies highlight the facility's failure to maintain a clean and safe environment, as evidenced by the missing personal belongings and the unaddressed maintenance issues in the residents' living areas.
Verbal Abuse and Supply Neglect in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect, as evidenced by multiple incidents involving staff interactions and inadequate supply provisions. Resident 14, who was cognitively intact, reported being verbally abused by a former administrator, Staff 20, during a COVID-19 isolation incident. Staff and witnesses corroborated that Staff 20 used an authoritative and aggressive tone, causing Resident 14 emotional distress and fear of retaliation, which prevented the resident from filing grievances. Additionally, the facility was found to have neglected the needs of several residents by failing to provide adequate incontinence supplies. Residents 3, 18, and 20, who were dependent on staff for toileting hygiene, experienced issues due to the lack of appropriately sized briefs and insufficient wipes. Complaints were made about the facility's inability to supply the correct size briefs, leading to skin irritation and discomfort for the residents. Staff confirmed that there were delays in supply orders and that donations were relied upon to meet the residents' needs. The facility's failure to provide necessary supplies and protect residents from verbal abuse highlights significant deficiencies in care. The lack of proper incontinence supplies resulted in physical discomfort and potential health risks for the residents, while the verbal abuse incident caused emotional harm. These issues were confirmed by staff interviews and resident statements, indicating systemic problems in the facility's management and care practices.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of its residents, as evidenced by the case of Resident 6, who expressed a desire to go fishing more often but was unable to do so due to the facility van being not road legal. The van's registration was out of date, and the title was still in the previous owner's name, preventing renewal. This issue was confirmed by multiple staff members, including the Maintenance Director, who acknowledged the problem but could not provide a timeline for resolution. The lack of a functioning van prevented residents from participating in outings, which was a source of dissatisfaction among them, as noted during a resident council meeting. Additionally, the facility experienced a period without an Activity Director, resulting in a lack of documented activities for several residents. A public complaint highlighted that the Social Services and Activity Directors' positions were vacant for a time, leading to no activities being available. Documentation for several residents showed minimal or no participation in activities during this period. Staff confirmed that activities were not occurring despite an activity calendar being posted, and the newly hired Activity Director noted that there were no activities on Sundays when she worked as a CNA before her current role.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by multiple instances of insufficient staff coverage. Resident 18, who has dementia and cognitive impairment, was left without a required staff escort for a medical appointment due to short staffing. The facility administrator acknowledged this lapse in care. Additionally, a public complaint highlighted that during certain shifts, the facility operated with only one nurse and one CNA for 27 residents, which did not meet the state minimum staffing requirements. This situation was corroborated by witness statements and a review of staffing reports, which showed numerous days where staffing levels were below the required minimum. Further observations revealed that residents experienced delays in receiving care and services. Resident 14, for example, had to wait several hours for assistance with a simple request for batteries for a television remote. Other residents reported long wait times for call light responses and medication administration. Staff members confirmed that the facility was short-staffed, particularly during the evening shifts, and that they struggled to provide timely care. The facility's administration was aware of these issues, as indicated by statements from the current administrator and interim DNS, who expected staff to address call light activations promptly.
Failure to Implement Infection Control Precautions for MRSA
Penalty
Summary
The facility failed to adhere to infection control standards for a resident who was readmitted with an active Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The resident, initially admitted with a hip fracture, was discharged to the hospital due to pus drainage from the surgical site and later returned to the facility with MRSA. Despite the serious nature of MRSA, there was no documentation in the resident's clinical record indicating that they were placed on any infection control precautions upon readmission. Staff interviews revealed a lack of awareness regarding the resident's MRSA status, and it was confirmed that the resident was not on any infection control precautions. The care plan provided by the facility indicated that precautions were only implemented 27 days after the resident's readmission. This oversight was highlighted by a public complaint received by the State Survey Agency, which also noted the removal of biohazard receptacles and multiple residents with MRSA infections.
Failure to Ensure Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure a follow-up dental appointment was made for a resident who was reviewed for dental care. The resident, admitted in April 2023 with a diagnosis of diabetes, underwent an oral exam on March 19, 2024, which revealed cavities and recommended a referral for treatment and a full crown. A subsequent dental visit on May 15, 2024, noted that X-rays could not be performed due to the resident's mental capacity. However, the resident's clinical record did not indicate that a referral to another dental provider was made. On November 8, 2024, the facility administrator confirmed that the resident was not set up for a dental referral related to the treatment recommendations from previous dental appointments.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs of Resident 8, who was admitted with hemiplegia and depression. Resident 8 was moved to a different room due to a ceiling leak, but the adaptive equipment necessary for bed mobility, such as a trapeze and side rails, was not transferred to the new room. This oversight left Resident 8 without essential adaptive equipment for over two months, as confirmed by both the resident and maintenance staff. Resident 14, admitted with arthritis and intervertebral disc degeneration, experienced issues with mobility and access to personal belongings. Despite being cognitively intact, Resident 14 was using a borrowed power wheelchair that was too large, preventing her/his feet from touching the floor and causing physical discomfort. Although a prescription for a new power wheelchair was requested, there was a lack of follow-up, and the insurance provider initially denied coverage due to incorrect information. Additionally, Resident 14's personal belongings were inaccessible as they were stored in boxes and placed too high in the closet, and staff had not assisted in unpacking them since her/his room change. The facility's failure to address these issues resulted in Resident 14's inability to access her/his belongings and use a properly fitting wheelchair, exacerbating her/his physical pain and anxiety. Staff interviews revealed a lack of awareness and responsibility regarding the unpacking of Resident 14's belongings, highlighting a gap in communication and care coordination within the facility.
Failure to Report Alleged Abuse by Former Administrator
Penalty
Summary
The facility failed to report allegations of abuse involving a resident who was cognitively intact and had been admitted with diagnoses including arthritis and intervertebral disc degeneration. The incident occurred when the resident, who had tested positive for COVID-19, refused to stay in their room. During this time, a former administrator, identified as Staff 20, was reported to have yelled at the resident, which was witnessed by other staff and residents. The resident felt bullied and described the interaction as emotional and psychological abuse, expressing discomfort in speaking with Staff 20 alone. Despite these allegations, there was no indication that the incident was reported to the State Survey Agency. Interviews with various staff members corroborated the resident's account of the events. Staff 25, a CNA, confirmed that Staff 20 yelled at the resident, while Staff 13 observed Staff 20 using an authoritative voice to direct the resident back to their room. Witness 7, a former staff member, noted that the resident did not file grievances due to fear of punishment and observed Staff 20 yelling and cussing in the hallway. Staff 18 also stated that the resident was uncomfortable talking alone with Staff 20. The facility's current administrator and interim DNS acknowledged that they expected such allegations to be reported, yet this was not done.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who was cognitively intact and had tested positive for COVID-19. The incident occurred when the resident was sitting by the elevator, and a staff member, identified as the former administrator, instructed the resident to return to their room in an authoritative manner. The resident expressed feeling bullied and emotionally abused by the staff member's behavior, which included loud talking and refusal to leave the resident alone when requested. Multiple staff members corroborated the resident's discomfort and the staff member's authoritative demeanor. Despite the resident's claims of emotional and psychological abuse, there was no documentation in the resident's clinical records indicating that an investigation was conducted regarding the incident. The facility's administrator and interim DNS acknowledged that an abuse investigation was expected to be completed, yet it was not carried out. This lack of action placed residents at risk for abuse, as the facility did not adhere to its obligation to investigate allegations of abuse thoroughly.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident who was dependent on staff for care. The resident, who was admitted in May 2023 with conditions including arthritis and intervertebral disc degeneration, was cognitively intact with a BIMS score of 15. The care plan indicated the resident required one-person assistance for most ADLs and was to use a call light for help. On November 6, 2024, the resident reported that after activating the call light, two CNAs responded but left the room without providing assistance, resulting in the resident waiting 45 minutes to an hour in a soiled brief. The CNAs, Staff 13 and Staff 19, left the room because the resident requested they keep quiet and not turn on the light to avoid waking the roommate. The CNAs reported the situation to other staff but did not return immediately to assist the resident. The facility's administrator and interim DNS stated that staff are expected to address such issues by problem-solving with the resident or involving a nurse. However, the CNAs did not follow this protocol, leading to a delay in care. Attempts to contact another staff member, Staff 11, who might have been involved, were unsuccessful.
Failure to Follow Physician Orders and Respond to Resident Needs
Penalty
Summary
The facility failed to respond to changes in condition and follow physician orders for two residents, leading to potential risks for delayed treatment and unmet needs. Resident 4, diagnosed with Parkinson's disease, constipation, and chronic kidney disease, had a physician order for Miralax to be administered if no bowel movement occurred for three days. However, the medication was not given until the sixth day, despite the resident having no bowel movement for five days, which was confirmed by the Director of Nursing Services (DNS). Resident 29, with diagnoses including dementia and a urinary tract infection (UTI), had a preference for limited treatment, including antibiotics. After returning from the hospital with new orders for Levofloxacin, the resident exhibited signs of distress, such as difficulty staying awake and eating, and later had oxygen levels at 64 percent with labored breathing. Despite these critical signs, a former LPN did not assess the resident promptly, even when the resident showed signs of choking and a black tongue. Staff members reported that the LPN was not responsive to the resident's needs, and attempts to contact the LPN for further clarification were unsuccessful.
Failure to Prevent Accidents and Monitor Residents After Falls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and adequately supervise residents, leading to incidents involving two residents. Resident 6, who was admitted with a stroke and identified as a high fall risk, experienced a fall due to malfunctioning entrance doors. The main entrance door was broken, forcing Resident 6 to use a back door with a ramp lacking railings. This resulted in the resident's electric wheelchair slipping off the ramp, causing a fall and injuries. Despite complaints and observations from staff about the non-functioning doors, there was no documentation or timeline provided regarding when the doors were repaired. Resident 18, also admitted with a stroke, experienced multiple falls due to inadequate supervision and failure to follow care plan interventions. On two occasions, Resident 18 attempted to self-transfer and fell, with the wheelchair brakes not being locked. Despite the unwitnessed falls, neurological assessments were not documented, as confirmed by staff. Additionally, the care plan did not reflect the use of non-slip material on the resident's wheelchair cushion, which was observed during the survey. These deficiencies highlight the facility's failure to ensure proper monitoring and updating of care plans for residents at risk of falls.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medications as ordered for a resident with chronic pain, leading to instances of uncontrolled pain. Resident 14, who was admitted in May 2023 with diagnoses including arthritis and intervertebral disc degeneration, had a care plan indicating the need for pain management with Methadone. However, there were multiple occasions documented in February and March 2024 where Methadone was not administered due to delays in delivery from the pharmacy or waiting on a physician order. These missed doses were not communicated to the resident's physician, and there was no documentation explaining the absence of medication on certain dates. The resident, who was cognitively intact with a BIMS score of 15, reported that their pain medications were frequently late or missed almost every month. Witnesses, including complainants, corroborated the resident's claims, stating that the facility consistently mismanaged the resident's medications, causing hardship. Despite the resident's frequent absences from the facility, staff acknowledged the expectation to notify the physician of any missed doses, which was not done in this case.
Failure in Timely Pharmaceutical Services for Pain Management
Penalty
Summary
The facility failed to provide accurate and timely pharmaceutical services for a resident with chronic pain, leading to missed doses of Methadone, a medication prescribed for pain management. The resident, who was admitted in May 2023 with diagnoses including arthritis and intervertebral disc degeneration, had a care plan indicating the need for pain medication as ordered by the physician. However, there were multiple instances in February and March 2024 where Methadone was not administered due to delays in delivery from the pharmacy or waiting on a physician order. These lapses were documented in the Medication Administration Notes, highlighting a pattern of medication mismanagement. The resident, who was cognitively intact with a BIMS score of 15, reported that their pain medications were frequently late or missed, affecting their daily activities and sleep. Witnesses, including complainants, corroborated the resident's claims, stating that the facility consistently mismanaged the resident's medications, causing hardship. The facility staff acknowledged the resident's frequent absences from the facility but did not provide a satisfactory explanation for the missed doses. This deficiency in pharmaceutical services placed the resident at risk for medication errors and inadequate pain management.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to unmet needs. A complaint was received indicating that a resident was not getting enough food and was not always served the same meals as other residents. The resident expressed dissatisfaction with the meal schedule, as the largest meal was served at lunch instead of dinner, which was contrary to their cultural preference. Additionally, the resident reported not being provided with meal choices and was served foods they disliked, such as beets and Brussels sprouts. When the resident requested a salad, it was reportedly small and lacking in ingredients. The resident also mentioned that the pork chop served was dry. The facility's alternative meal item list was reviewed and found to include options such as cottage cheese and fruit, hotdogs, corndogs, and sandwiches. However, it was noted that the alternative menu was removed during the tenure of a former administrator and had not been reinstated. Staff confirmed that the alternative meal item list was not nutritionally equivalent to the main menu. A CNA reported instances of small meal portions and confirmed that the alternative menu was no longer available, which contributed to the resident going to bed hungry on occasion.
Incomplete and Inaccessible Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accessible, affecting two residents whose records were reviewed. Resident 11, who was admitted in June 2019 with diagnoses including blindness and dementia, was involved in an incident where the State Survey Agency received a complaint about the disposal of medical records, including tuberculosis (TB) testing records, by a former administrator. This led to the need for re-testing, as there was no documentation of TB testing prior to June 2024. It was noted that Resident 11 refused a TB skin test in August 2024. Similarly, Resident 18, admitted in April 2023 with anxiety and dementia, was also affected by the loss of TB testing records. The complaint indicated that the former administrator disposed of these records, necessitating re-testing. There was no documentation of TB testing prior to August 2024, although records show that Resident 18 received a TB skin test in August 2024. Staff confirmed the loss of medical documents and the need to redo TB testing for some residents.
Delay in Radiology Services Due to Documentation Errors
Penalty
Summary
The facility failed to timely obtain radiology services for a resident, which resulted in a delay of approximately three months for a necessary MRI. The resident, who was admitted with a diagnosis of spinal stenosis, had a physician order for an MRI of the left knee issued in June 2024. However, due to inaccurate facility documentation, including the absence of a physician's signature and unclear imaging instructions, the MRI appointment was not scheduled until September 2024. Despite multiple calls from the complainant to update the order and add the physician's signature, the facility's lack of communication contributed to the delay. The Social Service Director acknowledged the delay in addressing the physician's order for radiology services.
Failure to Follow Care Plan Leads to Resident Abuse
Penalty
Summary
The facility failed to follow care plan interventions to protect residents from physical abuse, specifically involving two residents with dementia. Resident 1, who has a history of striking out and aggression, was observed to slap another resident on the hand. Following this incident, Resident 1's care plan was updated to ensure they remained at arm's length from other residents. However, this intervention was not effectively implemented. Subsequently, Resident 1 struck Resident 2 on the face while passing by the nursing station, despite the care plan's directive to keep Resident 1 at a safe distance from others. The facility's investigation ruled out abuse but did not confirm whether the care plan interventions were followed. Additionally, there was no documentation of the incident in the progress notes for either resident. Interviews with the current Administrator and DNS revealed acknowledgment that the care plan was not adhered to, leading to the incident.
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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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