Regency Florence
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, Oregon.
- Location
- 1951 E. 21st Street, Florence, Oregon 97439
- CMS Provider Number
- 385142
- Inspections on file
- 25
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Regency Florence during CMS and state inspections, most recent first.
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.
Failure to follow ordered skin treatment: A resident with a history of MS and prior cellulitis had a right lower leg venous ulcer that later resolved, but ordered dressing care continued. During an observed treatment, an RN rubbed the resident’s fragile right lower leg skin and called it light debridement before an LPN applied the ordered Xeroform, ABD pad, and Kerlix dressing. The DNS stated this rubbing was not part of the physician-ordered plan of care.
Infection control procedures were not followed during medication administration and wound-related care. An RN entered a resident’s room without hand hygiene, handled the resident’s cup and medications, and returned to the cart and computer without sanitizing hands. A CMA used a pill cutter without sanitizing it afterward and also entered and exited a resident’s room and accessed the med cart and computer without hand hygiene.
The facility failed to provide ordered therapy for a resident with stroke and diabetes, as therapy orders were not received by the OT/Therapy Manager. Another resident with a Stage 4 pressure ulcer and quadriplegia-incomplete was left without incontinence care during the night shift, found soiled in the morning, and their call light was out of reach. An investigation determined that a CNA failed to provide appropriate care.
A facility failed to thoroughly investigate an abuse allegation involving a resident with failure to thrive. An LPN allegedly threatened to administer an extra dose of oxycodone, causing the resident anxiety. The LPN later claimed the extra dose was given to another resident. The investigation lacked witness statements and interviews with involved parties, as acknowledged by the DNS.
A resident admitted with depression received a COVID-19 vaccine without documented informed consent. A review of the medical records months later revealed the absence of a signed consent form, which was confirmed by the DNS during an interview.
A resident admitted with a stroke diagnosis did not have an advance directive documented despite expressing a desire for one during multiple care conferences. The Social Service Director claimed to offer advance directives but did not follow up, and the facility administrator expected staff to ensure follow-up before quarterly care conferences, which was not done.
A resident with heart disease was prescribed Ipratropium-Albuterol Inhalation Solution for five days to treat shortness of breath. However, the medication was administered for seven days beyond the prescribed discontinuation date. The DNS acknowledged the error, which placed the resident at risk of receiving unnecessary medications.
A resident did not receive prescribed corrective lenses after an eye exam, leading to unmet vision needs. The resident had an eye exam where glasses were prescribed, but months later, they reported not receiving them. The Social Service Director was unaware of the order, and the DNS acknowledged the lack of timely follow-up.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident, with severe cognitive impairment, had a history of trauma from the Vietnam War, but her/his care plan lacked specific PTSD triggers or interventions. Staff were unaware of her/his PTSD or triggers, such as loud noises. Another resident, cognitively intact, had a history of abuse and PTSD, but her/his care plan also lacked specific triggers or interventions. Staff were not informed of her/his triggers, including yelling and male staff presence.
The facility failed to address pharmacy recommendations for two residents, leading to potential risks. A resident with depression did not have a timely dose reduction of citalopram, and another with heart disease did not have updated orders to administer carvedilol with food. Staff confirmed these oversights.
The facility failed to process lab orders timely for two residents, risking unnecessary medications. A resident with depression had a comprehensive metabolic panel ordered in May, completed in September. Another resident had a lipid panel ordered in August, completed in September. The DNS acknowledged these delays.
A resident admitted with depression expressed the need for a dental appointment for new dentures during a care conference. Despite this, the facility failed to schedule the appointment, as confirmed by an LPN, resulting in unmet dental needs.
The facility failed to assess and monitor pressure ulcers for two residents, leading to unassessed and unmet treatment needs. One resident developed a new pressure injury on the left heel, which was not documented or monitored, and care plans were not consistently followed. Another resident developed multiple pressure injuries, including an unstageable ulcer, without proper documentation, investigation, or care plan updates.
The facility failed to monitor a resident at risk for elopement, resulting in the resident leaving the facility and falling from a wheelchair. Additionally, another resident, who required assistance, was left alone in the shower, causing fear of falling. Staff interviews confirmed these lapses in supervision and adherence to care plans.
The facility failed to provide timely incontinence care for three dependent residents, leading to unmet care needs. One resident with dementia and TBI was found soaked and not repositioned for over three hours. Another resident with cerebral palsy was found with a wet bath blanket instead of changed bed sheets. A third resident on end-of-life hospice care was also found with wet spots and dried bowel movement. The facility's investigation confirmed the lack of appropriate and timely care.
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.
Failure to Follow Ordered Skin Treatment
Penalty
Summary
The facility failed to follow physician orders for a resident with a history of multiple sclerosis and prior cellulitis of the right lower leg. The resident was admitted with a right lower leg venous ulcer that was documented on admission as 4 cm by 4 cm with a small amount of serosanguineous drainage. A later weekly skin evaluation documented that the ulcer had resolved, but treatment to the right lower leg continued. A physician order dated 4/22/26 directed right lower extremity dressing changes with cleansing using wound cleanser, application of Xeroform, ABD pad, Kerlix wrap, and securing the dressing on Monday, Wednesday, and Friday evenings. During an observed treatment, the existing dressing had already been removed, no open areas were seen, and the skin on the right lower leg was flaking and yellowed. The RN performing the treatment stated she was doing light debridement by running gloved hands up and down the resident's right lower leg before the LPN applied the ordered dressing. The DNS stated this rubbing was not part of the physician ordered plan of care and that staff should never rub fragile skin around a healed or healing wound.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure staff followed infection control procedures during wound care and medication administration for one sampled resident with pressure wounds and during medication administration for one resident. During a medication administration observation, an RN entered the resident’s room without performing hand hygiene, handled the resident’s water cup, provided eye drops and nasal spray, moved multiple cups on the overbed table, handled the medication cup and the medication bottles, and then returned to the medication cart and computer without sanitizing hands. The RN stated hand hygiene should be performed before entering and after exiting a resident’s room. During another medication administration observation, a CMA used a pill cutter to cut a medication and returned the pill cutter to the medication cart drawer without sanitizing it. The CMA then entered and exited the resident’s room without performing hand hygiene and accessed the computer and medication cart without hand hygiene. The Administrator, DNS, and Regional Nurse Consultant later stated staff should sanitize their hands before entering and after exiting a resident’s room, sanitize all equipment after each use including the pill cutter, and clean resident inhalers, eye/ear drops, and nebulizers after each use.
Failure to Provide Ordered Therapy and Incontinence Care
Penalty
Summary
The facility failed to follow physician orders for therapy for Resident 102, who was admitted with diagnoses including stroke and diabetes. Despite having admission orders for Physical and Occupational Therapy dated 9/12/24, the resident did not receive any therapy during their nine-day stay. Staff 15, the OT/Therapy Manager, stated they had not received therapy orders, and the facility's administrator was unable to locate any documentation explaining the lack of therapy provided. Resident 104, admitted with a Stage 4 pressure ulcer and quadriplegia-incomplete, was not provided incontinence care during the night shift and was found soiled in the morning with the call light out of reach. An investigation revealed that Staff 16, a CNA, failed to provide appropriate care, leaving the resident without care through the night. Staff 8 discovered the resident in a soiled state and was informed by the resident that Staff 16 and another CNA had started but not completed changing them, leaving wipes and a brief on the bed.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving a resident who was admitted with a diagnosis of failure to thrive. On September 12, 2024, a public complaint was received alleging that a former agency LPN threatened to administer an extra dose of oxycodone to the resident, causing them to feel threatened and anxious. The resident reported that the LPN later claimed to have given the extra dose to another resident, which further upset the resident. A CNA corroborated the resident's account, stating that the resident panicked and became upset after the LPN's statements. The facility's investigation into the incident was incomplete, lacking witness statements, interviews with other residents, and an interview with the alleged perpetrator. The Director of Nursing Services acknowledged the investigation's deficiencies.
Failure to Obtain Informed Consent for COVID-19 Vaccine
Penalty
Summary
The facility failed to obtain informed consent prior to administering a COVID-19 vaccine to a resident. The resident, who was admitted in April 2024 with a diagnosis of depression, received the vaccine in May 2024. However, upon review of the resident's medical records in December 2024, there was no evidence of a signed consent form for the vaccine. The Director of Nursing Services (DNS) confirmed the absence of the consent form during an interview conducted in December 2024.
Failure to Document Advance Directives for a Resident
Penalty
Summary
The facility failed to obtain and document information related to advance directives for a resident who was admitted in October 2021 with a diagnosis of stroke. Despite attending multiple Interdisciplinary Care Conferences, the resident expressed a desire to have an advance directive offered, yet none was documented in their electronic record. On December 3, 2024, the resident confirmed not being offered an advance directive during these conferences. The Social Service Director claimed to offer advance directives at care conferences and had residents sign an Admission Assessment document to verify receipt, but admitted to not conducting follow-up related to the provision of advance directives. The facility administrator expected staff to follow up on advance directives before quarterly care conferences, which was not done in this case.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to adhere to a doctor's orders regarding the administration of medication for a resident diagnosed with heart disease. The resident was prescribed Ipratropium-Albuterol Inhalation Solution to treat shortness of breath for a duration of five days, starting on November 22, 2024. However, a review of the Medication Administration Records (MARs) for November and December 2024 revealed that the medication was administered beyond the prescribed period, continuing until December 4, 2024, which is seven days past the discontinuation date of November 27, 2024. During an interview on December 4, 2024, at 4:00 PM, the Director of Nursing Services (DNS) acknowledged that the resident continued to receive doses of the medication beyond the ordered discontinuation date. This oversight placed the resident at risk of receiving unnecessary medications.
Failure to Provide Corrective Lenses
Penalty
Summary
The facility failed to address orders for corrective lenses for a resident, which placed them at risk for unmet vision needs. The resident was admitted to the facility with a diagnosis of depression and had an eye exam on June 3, 2024, where a prescription for glasses was written. However, by December 2, 2024, the resident reported not having received the glasses. The Social Service Director was unaware of the order for new glasses, and the Director of Nursing Services acknowledged that the resident did not receive timely follow-up for the new glasses.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with PTSD and other behavioral needs. Resident 11, who was admitted in January 2017, had a history of trauma from the Vietnam War and a gunshot wound. Despite having severe cognitive impairment, as indicated by a BIMS score of five, Resident 11's care plan did not include specific triggers or interventions related to her/his PTSD. Interviews with staff revealed that they were unaware of the resident's PTSD or specific triggers, which included loud noises that made her/him upset and scared. Similarly, Resident 30, admitted in November 2021, had a history of abuse and PTSD, along with other diagnoses such as stroke and depression. Although Resident 30 was cognitively intact with a BIMS score of 15, her/his care plan lacked specific triggers or interventions related to her/his PTSD. The resident reported that triggers included people yelling and male staff entering her/his room, yet staff were not informed of these triggers. The Director of Nursing Services confirmed that neither resident had care plans addressing their specific trauma triggers or interventions.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication reactions and unnecessary medications. Resident 1, admitted with a diagnosis of depression, had pharmacy consultation reports recommending a gradual dose reduction of citalopram in September and October 2024. However, there was no evidence of a signed physician order to attempt this reduction in September, and the order to decrease the dosage was only made in October. Staff confirmed that the pharmacy recommendation was not completed in a timely manner. Resident 24, admitted with heart disease, had a pharmacist review in September 2024 that instructed the facility to clarify the order for carvedilol to ensure it was administered with food. A review of the resident's medication administration record and physician orders in December 2024 revealed that the orders were not updated to include this instruction. Staff acknowledged that the orders were not updated to reflect the need to administer carvedilol with food.
Delayed Processing of Laboratory Orders for Two Residents
Penalty
Summary
The facility failed to process physician laboratory orders in a timely manner for two residents, which placed them at risk for unnecessary medications. Resident 1, admitted in April 2024 with a diagnosis of depression, had a physician order for a comprehensive metabolic panel on May 7, 2024, to be completed on the next lab day and every six months. However, the test was not completed until September 7, 2024. Staff 2, the Director of Nursing Services (DNS), acknowledged the delay in completing the test. Similarly, Resident 20, admitted in August 2024 with a diagnosis of depression, had a physician order for a lipid panel on August 9, 2024, to be completed the next lab day and every 12 months. This test was not completed until September 5, 2024. Staff 2 also acknowledged this delay. These delays in processing laboratory orders were identified during interviews and record reviews.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a dental appointment for a resident who was admitted in April 2024 with a diagnosis of depression. During a care conference in October 2024, the resident expressed the need for a dental appointment to obtain new dentures. However, as of December 2024, the appointment had not been scheduled. This oversight was confirmed by a Licensed Practical Nurse (LPN) Resident Care Manager, who acknowledged that the resident did not receive timely follow-up for their dental needs.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to assess and monitor pressure ulcers for two residents, leading to unassessed and unmet treatment needs. Resident 11, admitted with dementia, developed a new pressure injury on the left heel, which was not documented or monitored in the medical record. Despite care plans indicating the need to float the resident's heels with pillows, observations showed the resident lying in bed without a pillow under the feet on multiple occasions. Staff were aware of the bruising but did not ensure consistent implementation of the care plan or document the wound assessment. Resident 94, admitted with diabetes, developed multiple pressure injuries, including an unstageable pressure ulcer on the right heel and injuries to the coccyx and left thigh. These injuries were not documented in incident reports or investigated, and no Skin and Wound Evaluations were conducted. The resident reported pain and lack of assistance with repositioning, and staff acknowledged the development of pressure wounds but did not update the care plan or ensure proper documentation and investigation of the injuries.
Failure to Monitor Elopement Risk and Adhere to Care Plans
Penalty
Summary
The facility failed to adequately monitor and supervise residents at risk for elopement and ensure adherence to care plans related to safety. Resident 8, who was admitted with dementia and identified as having severe cognitive deficits, was at risk for elopement as indicated by an evaluation. Despite being an active exit seeker, Resident 8 managed to elope from the facility after multiple attempts to leave, eventually being found outside after falling from a wheelchair. Staff interviews revealed that Resident 8 had figured out the door code and attempted to exit the facility multiple times, yet was not placed under one-to-one supervision as acknowledged by the facility administrator. Additionally, the facility did not follow the care plan for Resident 93, who was admitted with diabetes and required one-person assistance while showering. A public complaint and subsequent interviews confirmed that Resident 93 was left alone in the shower, causing fear of falling. The Social Service Director was informed of the incident, and an agency LPN admitted to leaving Resident 93 unattended for approximately 10 minutes. The facility administrator acknowledged that residents should not be left alone in the shower unless deemed independent by therapy, which was not the case for Resident 93.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three dependent residents, leading to unmet care needs. Resident 101, who has dementia and a traumatic brain injury, was found soaked and not repositioned for over three hours despite being on a Check and Change toileting program. Staff 8 initially claimed to have provided care but later admitted to not doing so, and no assistance was sought from other staff members. The facility's investigation confirmed the lack of care provided by Staff 8. Resident 102, diagnosed with cerebral palsy and left-sided hemiparesis, was also on a Check and Change toileting program. Staff 9 failed to change the resident's wet bed sheets, instead placing a bath blanket under the resident, which was found wet. The resident was later found soaked with urine and had dried bowel movement on their behind. The facility's investigation determined that Resident 102 did not receive appropriate or timely incontinence care. Resident 103, who has dementia and is on end-of-life hospice care, was similarly neglected. Staff 9 placed a bath blanket under the resident instead of changing the soiled bed sheets. The resident was found with wet spots under the blanket and was soaked with urine and had dried bowel movement on their behind. The facility's investigation confirmed the lack of appropriate and timely incontinence care for Resident 103.
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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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