Nehalem Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeler, Oregon.
- Location
- 280 Rowe Street, Wheeler, Oregon 97147
- CMS Provider Number
- 385244
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Nehalem Valley Care Center during CMS and state inspections, most recent first.
A dependent hospice resident with cancer, mixed bladder incontinence, and a coccyx pressure injury was not provided incontinent care or repositioning for about seven hours, despite a care plan requiring checks, changes, and turning at least every two hours. A CNA assigned to the resident acknowledged she only visually checked the brief once, did not change it, and did not reposition the resident due to the resident’s pain, and later wrote a note asking others to keep an LPN from entering the room because care had not been done. Other CNAs and the charge RN reported it was apparent the resident had not been changed, and staff confirmed that standard practice was to provide incontinence care and repositioning per the care plan.
The facility did not provide RN coverage for eight consecutive hours on three reviewed days, as confirmed by staff interviews and daily staffing reports.
The facility did not maintain adequate nursing staff levels, resulting in missed showers, delayed meal service, and prolonged call light response times. Residents reported waiting up to an hour for assistance, and staff confirmed frequent understaffing and difficulty completing basic care tasks in a timely manner.
Staff failed to follow infection control protocols by not donning PPE or performing hand hygiene when entering and exiting rooms of two residents on Contact Precautions, and by not cleaning reusable equipment between uses. Additionally, a CNA was observed wearing the same gloves while assisting multiple residents during meal service, handling food and personal items without changing gloves or performing hand hygiene between tasks.
Two residents were served meals in the dining room using trays covered with black plastic garbage bags, disposable containers, and plastic utensils, while seated with other residents who had standard meal service. Staff initially indicated this was for residents on precautions, but a regional nurse confirmed this was not required by protocol. Both residents expressed a desire to have the same meal service as others.
A resident with dementia was prescribed multiple psychoactive medications, including an antipsychotic, despite showing increasing side effects as measured by AIMS scores. Staff and leadership acknowledged that the antipsychotic was used to address calling out behaviors that were not distressing to the resident, and no comprehensive assessment or gradual dose reduction was performed, with the facility relying on pharmacist reviews instead of their own evaluations.
Staff prepared pureed meals for two residents by adding water to roasted salmon instead of using hot cooking liquid or broth as required by the facility's recipe. The dietary manager confirmed that water should not be used, as it does not provide the necessary nutritional value for residents on pureed diets.
The facility failed to maintain RN coverage for at least eight consecutive hours a day on 41 out of 99 days, risking unmet assessment needs. Additionally, there was no full-time DNS present, leading to confusion and lack of clinical oversight, as confirmed by staff interviews.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and repositioning assistance to a dependent resident over a seven-hour period. The resident had diagnoses including cancer and was on hospice, with a care plan indicating mixed bladder incontinence and dependence on staff for toileting. The care plan directed staff to check and change the resident during repositioning, as needed, and throughout the shift, and also documented a pressure injury to the coccyx with instructions for turn/repositioning at least every two hours and more often as needed. On the day in question, a CNA assigned to the resident did not provide incontinent care or repositioning for approximately seven hours of her shift, despite being responsible for these cares. Interviews and the facility’s investigation showed that the CNA acknowledged she had only looked at the resident’s brief early in the shift, thought it appeared dry, and left it unchanged, and that she did not reposition the resident because the resident grimaced in pain when she pulled on the pad. Other CNAs reported that the CNA wrote a note on the CNA message board asking others not to let the nurse enter the resident’s room because the resident had not yet been changed, and that it was obvious to staff later in the shift that the resident had not been changed. The charge nurse became aware near the end of the shift that the resident had not received care, and other CNAs were asked to assist with completing the resident’s cares. Staff interviews confirmed that standard practice was to provide incontinence care and repositioning at least every two hours or according to the care plan, and the administrator acknowledged that the resident was not provided ADL assistance by the CNA for a prolonged period of time.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours per day on three specific days out of forty-three days reviewed. Direct Care Staff Daily Reports showed that there was no RN coverage for the required duration on 2/13/25, 2/15/25, and 6/20/25. This deficiency was confirmed through interviews with the Administrator and Regional Nurse, who acknowledged the lack of RN coverage on the identified days. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents in a timely manner across all three resident halls reviewed. Resident Council notes documented missed showers and delays in getting residents to activities and meal service. Review of Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates. Residents reported significant delays in call light responses, with some waiting up to an hour for assistance, experiencing late showers, and receiving meals late. Some residents had to leave their rooms to seek help due to the lack of available staff. Staff interviews confirmed ongoing staffing shortages, with CNAs frequently assigned to care for 8-12 residents, making it difficult to complete basic care tasks and respond to call lights promptly. Staff described feeling rushed and unable to provide timely showers or assistance, and agency CNAs corroborated that it was common for residents to wait over 20 minutes for call lights to be answered. The facility administrator acknowledged the staffing concerns and the impact on timely resident assistance.
Failure to Implement Proper Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE) for residents on Contact Precautions. Staff were observed entering and exiting rooms of residents on Contact Precautions without donning appropriate PPE or performing hand hygiene, despite clear signage and facility policy. In one instance, a CNA entered a resident's room twice without PPE and did not perform hand hygiene upon exit. In another case, an LPN entered a resident's room without PPE, used a reusable blood pressure device without cleaning it afterward, and placed it on a medication cart without a barrier. Both staff members acknowledged their failure to follow proper procedures, and facility leadership confirmed that staff were confused about the differences between Enhanced Barrier Precautions and Contact Precautions. Additionally, during meal service in the main dining room, a CNA was observed wearing the same gloves while assisting multiple residents, handling food items, touching personal items such as a phone, and performing various tasks without changing gloves or performing hand hygiene between residents. The CNA admitted to only changing gloves and performing hand hygiene twice during meal service and recognized that hand hygiene should have been performed after touching personal items. Facility leadership confirmed that staff were expected to perform hand hygiene between assisting residents in the dining room.
Failure to Provide Dignified Dining Experience for Residents on Precautions
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were observed receiving their meals in the dining room with black plastic garbage bags covering their trays. The meals were served in disposable clamshell containers, with fruit in disposable paper soup cups, and plastic utensils provided, while the residents sat at a communal table with others who did not have similar arrangements. Staff explained that these trays were for individuals on precautions, but the regional nurse later clarified that the use of plastic bags, clamshell containers, and disposable utensils was not part of the protocol for residents on contact precautions. Both affected residents expressed a preference for having a normal tray and being treated like the other residents.
Failure to Assess and Address Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident with dementia was free from unnecessary use of antipsychotic medication. The resident was admitted with diagnoses including a stage four pressure ulcer and dementia, and was prescribed multiple psychoactive medications, including quetiapine, trazodone, venlafaxine, Namenda, and hydroxyzine. Despite the presence of symptoms and side effects associated with psychoactive medication use, as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS) scores, the facility did not adequately assess the continued need for antipsychotic medication. The physician was notified of certain symptoms and reduced the dose of venlafaxine, but did not address the use of quetiapine. The Psychotropic Committee did not order additional gradual dose reductions (GDRs) or assess the appropriateness of continued antipsychotic use despite adverse side effects. Observations and staff interviews indicated that the resident did not exhibit negative behaviors or signs of distress, and staff reported that calling out behaviors had lessened and were not distressing to the resident. However, the facility relied on pharmacist reviews rather than conducting their own assessments for antipsychotic medication use. Facility leadership acknowledged that antipsychotic medication was prescribed to address calling out behaviors that were disturbing to others, but not distressing to the resident, and admitted that a comprehensive risk/benefit assessment should have been completed in light of the adverse side effects.
Improper Preparation of Pureed Foods Using Water Instead of Nutritive Liquids
Penalty
Summary
The facility failed to ensure that pureed foods were prepared using methods that conserved nutritive value and flavor for residents requiring pureed diets. During two observed meals, a cook was seen adding approximately 6-8 ounces of water to roasted salmon while preparing a pureed meal for a resident, instead of using hot cooking liquid or hot broth as specified in the facility's recipe. The cook confirmed the use of water, and the dietary manager later stated that water should not be used for pureed meals, emphasizing that a liquid with more nutritional value was required. This practice resulted in the preparation of pureed food that did not meet the facility's standards for nutritional value and flavor.
Deficiency in RN Coverage and Lack of Full-Time DNS
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, as required, for 41 out of 99 days reviewed. This deficiency was confirmed by the facility's administrator, who acknowledged the absence of RN coverage on the specified dates. The lack of consistent RN presence placed residents at risk for unmet assessment needs, as there was no qualified nursing staff available to address potential health concerns during these periods. Additionally, the facility did not have a designated full-time Director of Nursing Services (DNS) for an extended period. Staff interviews revealed that the previous DNS had left in October 2024, and since then, an RN consultant was working remotely as the DNS, but was not physically present in the facility. This absence of a full-time DNS led to confusion among staff, who reported difficulties in identifying leadership and obtaining guidance for clinical questions. The lack of on-site nursing oversight further compromised the facility's ability to manage residents' clinical needs effectively.
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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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