Saint Helens Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Helens, Oregon.
- Location
- 75 Shore Drive, Saint Helens, Oregon 97051
- CMS Provider Number
- 385222
- Inspections on file
- 31
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Saint Helens Post Acute during CMS and state inspections, most recent first.
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.
The facility failed to timely report two separate allegations of abuse and neglect to the State Agency. In one case, a resident with severe cognitive impairment and an anoxic brain injury developed significant swelling and bruising of the right knee, later confirmed as a fracture, which was known to staff but not promptly reported to administration or the State Agency. In another case, a resident with dementia and moderate cognitive impairment, dependent on toileting and personal hygiene, was allegedly left without incontinence care for an entire CNA shift, and this neglect allegation was not reported to the State Agency within the required two-hour timeframe. Leadership, including the DON and Administrator, acknowledged that both incidents were reported late.
A resident with an anoxic brain injury, severe cognitive impairment, and poor impulse control developed swelling and later bruising of the right knee, which an RN assessed as significantly bruised and swollen before ordering an x-ray that confirmed a fracture. The DNS initially assessed the knee swelling without bruising and concluded the injury was likely self-inflicted, and a subsequent facility report attributed the injury to the resident kicking the bed footboard. The resident could not explain how the injury occurred, the RN did not believe it was self-inflicted, and there was no documented evidence that a thorough investigation into this injury of unknown source was completed, as confirmed by the Administrator.
A resident with hypothyroidism and other chronic conditions had a physician order for daily oral thyroid medication, but multiple doses were not administered over several days, as documented on the MAR and in nursing notes indicating the drug was on order, unavailable, and later on pharmacy back-order. Although staff contacted the pharmacy and noted an expected delivery, there was no documentation that the provider was notified of the missed doses or that an alternative source for the medication was pursued. In interviews, an LPN described a process for notifying leadership and the provider when medications are unavailable, and facility leadership stated they would have expected the provider to be informed of the unavailability and missed doses.
A resident undergoing evaluation for TB was not consistently placed on airborne precautions as ordered. The resident participated in group therapy and communal activities without a mask, and staff frequently entered the shared room without PPE or following infection control protocols. The airborne precaution signage was incomplete, and staff were not fully aware of the required practices, resulting in a failure to implement proper infection control measures.
A resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping, resulting in the catheter tubing being forcibly removed and causing severe pain. Staff and the resident confirmed the incident led to significant distress and ongoing discomfort, with multiple CNAs witnessing the aftermath and providing support.
A resident with Parkinson's disease had discrepancies between the MAR and narcotic logbook regarding Tramadol administration, with records showing conflicting information about the number and timing of doses given. Staff, including several LPNs and the DNS, confirmed the inconsistency but could not recall specific details about the medication administration.
The facility did not ensure RN coverage for at least eight consecutive hours per day on several occasions, as identified in staffing reports. This deficiency was confirmed by the Staffing Coordinator and Executive Director, acknowledging the failure to meet required staffing levels.
The facility did not implement a QAPI program to address quality deficiencies related to abuse, investigations, timely reporting, and immunizations, risking suboptimal resident care. The QAPI policy emphasized a proactive approach, but the Executive Director failed to ensure annual reviews by the QAA committee. Staff confirmed the absence of a relevant QAPI program.
The facility failed to implement effective systems for identifying problems and improving performance, as evidenced by the absence of procedures for problem identification, analysis, and monitoring in their 2024 QAA records. Despite having a QAPI Plan covering various services, there was no evidence of enacted procedures for systematic analysis and performance improvement, acknowledged by the DNS and Regional Director of Clinical Operations.
The facility did not ensure that state survey inspection results were accessible to residents and the public. The notice was placed too high for wheelchair users, and the survey binder was missing from its designated location. Residents were unaware of where to find the results, and the binders were stored out of reach behind the nurses' station.
Expired medications were found in the medication storage room and on multiple medication carts in the facility. Staff members, including CMAs and an LPN, confirmed the presence of expired medications such as Latanoprost eyedrops, MiraLAX, and Lispro insulin, but were unsure about the facility's policy on handling expired medications. The DNS stated that the policy required regular checks and removal of expired medications.
During an influenza outbreak, the facility failed to monitor dishwasher temperatures daily, risking communicable diseases and un-sanitized dishware. The temperature log for the low-temperature dishwasher had multiple blanks for January 2025. Staff confirmed the logs were to be filled out daily, and the dietary manager stated all kitchen staff were in-serviced on the procedure.
The facility's assessment was incomplete, lacking critical evaluations such as third-party agreements, risk assessments, and infection control plans. It also failed to consider resident care needs and cultural factors, placing residents at risk for inadequate care.
The facility failed to ensure that three cognitively intact residents understood the arbitration agreement they signed upon admission. Despite the Business Office Manager's claim that the form was explained and questions were welcomed, the residents either did not remember signing the form or did not understand what arbitration meant. This oversight placed residents at risk of being uninformed about their legal rights.
The facility failed to offer influenza vaccines to two residents, one with traumatic brain injury and another with COPD, despite consents being in place. Documentation was lacking for the administration of the vaccine in 2024, and staff interviews revealed issues with obtaining consents, particularly with agency staff.
The facility failed to provide two residents with information about the risks and benefits of the COVID-19 vaccine, as required by policy. One resident, admitted in 2014 with a traumatic brain injury, had a representative refuse the vaccine in 2023, but there was no documentation of information being provided in 2024. Another resident, admitted in 2024 with COPD, also lacked documentation of receiving vaccine information. Staff interviews revealed issues with obtaining consents, particularly with agency staff.
A facility failed to maintain a comfortable environment in a shower room, leading to an uncomfortable bathing experience for residents. A resident reported cold ambient air, and a surveyor confirmed the issue, noting a sign warning against using the heater due to a fire hazard. The Executive Director acknowledged the problem and confirmed the heater needed replacement.
The facility failed to thoroughly investigate and document abuse allegations involving staff and residents. In multiple instances, investigations lacked statements from alleged perpetrators, and there was no documentation of complaints or disciplinary actions. The facility did not conduct staff training related to abuse or have a tracking system for abuse concerns, and there were no PIPs or audits in place for abuse allegations.
The facility failed to report allegations of verbal and physical abuse within the mandated timeframe for three residents, placing them at risk for further abuse. A resident with cirrhosis and cognitive impairment was allegedly verbally abused by a CNA, but the incident was reported three days late. Another resident with a history of stroke reported potential abuse, but the FRI was submitted a day late. A third resident experienced potential verbal abuse, with the FRI submitted three days late. The DNS confirmed these delays, which did not meet the required reporting timeframe.
The facility failed to thoroughly investigate alleged abuse incidents involving three residents. Investigations lacked statements from accused staff and witnesses, leading to incomplete documentation and premature staff termination. No abuse audits were conducted following these allegations.
The facility failed to follow care plans and physician orders for three residents, leading to delayed treatment and unmet needs. A resident with epilepsy did not have required Dilantin level monitoring, resulting in hospitalization for toxicity. Another resident on anticoagulant therapy had unmonitored bruising, and a third resident involved in an alleged abuse incident had no documented skin or behavior monitoring.
A facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) letters to a resident, which is necessary to inform them of their right to appeal the termination of services. The resident was not notified of the scheduled end of services, as confirmed by the Executive Director and Social Services Director.
A resident with dental caries and broken teeth did not have their dental needs addressed in their care plan for nearly a year after admission. Despite staff awareness and a request for a dental visit, no action was taken, and a comprehensive care plan was only established much later.
A resident with a traumatic brain injury and contractures was not provided adequate incontinence care, as required by their care plan. Staff and family observations indicated that the resident was not always cleaned properly, with feces left in the groin area. The issue was reported to the administration, but they were unaware of any current concerns, and no grievance had been filed.
A resident with dental caries and broken teeth did not receive timely dental care, despite staff awareness and documentation of the issue. The resident's care plan lacked any reference to dental needs, and a dental appointment was only scheduled over a year after admission.
A resident's Oxycodone, brought from home due to a pharmacy delay, was misappropriated in an LTC facility. Discrepancies between the MAR and narcotic logbook were found, and the medication was not returned upon discharge. Staff interviews revealed a lack of procedures for handling medications brought from home.
A facility failed to provide restorative services to a resident with lupus, depression, and obesity, who wished to exercise to gain strength for discharge. Despite being cognitively intact, the resident received no exercise opportunities or equipment, and staff confirmed the absence of restorative services due to staffing issues. The administrator acknowledged the deficiency and the need to maintain residents' physical strength.
A resident with encephalopathy and dementia was discharged from the facility without receiving a written discharge notice. The resident's representative was also not notified or provided with documentation of the discharge. Staff confirmed that the necessary discharge paperwork was not completed or given to the resident before the discharge.
A resident with dementia and encephalopathy eloped from the facility due to inadequate supervision. The resident, identified as a fall risk, was found a mile away from the facility. Staff interviews and records confirmed that the facility was short-staffed, lacking two CNAs on the day of the incident, which contributed to the inability to monitor residents effectively.
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.
Failure to Timely Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and neglect to the State Agency as required. For one resident with an anoxic brain injury, severe cognitive impairment, and a BIMS score of 0, staff first noted swelling of the right knee on 10/11/25. An RN later observed significant bruising and swelling and ordered an x-ray, which identified a right knee fracture. The facility’s investigation concluded the injury was likely self-initiated from kicking the bed’s footboard, but the RN stated the resident did not know how the injury occurred and she did not believe it was self-inflicted. The DNS stated staff became aware of the knee swelling on 10/11/25, but administration did not report the incident until 10/13/25, and she acknowledged she was aware of the incident but had not reported it to the State Agency because staff failed to report it to management. An LPN confirmed she was initially made aware of the suspected injury on 10/11/25 and did not report it to administration, assuming the facility was already aware. The Administrator confirmed the facility did not report the incident within the required time. The deficiency also includes a separate neglect allegation involving another resident with dementia, a BIMS score of 11 indicating moderate impairment, and dependence on toileting and personal hygiene. A facility-reported incident documented that on 3/15/25 a CNA allegedly failed to complete incontinence care for this resident throughout an eight-hour shift. The DON confirmed the facility reported this neglect allegation to the State Agency on 3/17/25, acknowledging it should have been reported within two hours. The Administrator also confirmed the facility did not report this neglect allegation within the required time frame.
Failure to Thoroughly Investigate Resident’s Knee Fracture of Unknown Source
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct a thorough investigation into an injury of unknown source for one resident. The resident, admitted in 2/2013, had an anoxic brain injury and a care plan dated 1/12/25 documenting impaired cognitive function, poor impulse control, difficulty with self-expression, decision making, and mental status. A 3/31/25 MDS showed a BIMS score of 0/0, indicating severe cognitive impairment. On 10/11/25, staff first noted swelling of the resident’s right knee. The DNS (Staff 2) reported that upon her examination at that time, she noted no bruising and concluded the injury was likely self-inflicted due to the resident’s poor impulse control. An x-ray ordered on 10/13/25 revealed a right knee fracture. A facility investigation report dated 10/23/25 documented swelling and bruising of the right knee and concluded the injuries were likely from the resident kicking the bed footboard. However, an RN (Staff 26) stated that when she was informed of the swelling and examined the resident, she observed significant bruising and swelling and ordered the x-ray that confirmed the fracture. Staff 26 also stated the resident did not know how the injury occurred and that she did not believe it was self-inflicted. There was no documented evidence that the facility completed a thorough investigation into this injury of unknown source, and the Administrator (Staff 1) confirmed that the facility did not thoroughly investigate the resident’s injury.
Failure to Administer Ordered Thyroid Medication and Notify Provider
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for thyroid medication for one resident. The resident was admitted in December 2024 with diagnoses including polyneuropathy, inflammatory cervical spondylosis, and hypothyroidism. A physician’s order dated 1/4/2025 directed that the resident receive Thyroid Oral 90 mg daily by mouth for hypothyroidism. The January 2025 MAR showed that the thyroid medication was not administered on 1/19, 1/20, 1/22, 1/23, and 1/24, with directions to see nursing notes. Nursing progress notes on 1/19 and 1/20 documented that the thyroid medication was on order, and notes on 1/22 and 1/23 documented that the medication was unavailable. On 1/24, nursing documentation indicated the facility contacted the pharmacy and was informed the thyroid medication was on back-order, with a later note the same day stating the medication was expected to be delivered that night. Review of the clinical record showed no documentation that the provider was notified of the missed doses or that attempts were made to obtain the medication from an alternative source. In interviews, an LPN stated that if a medication was out or on back-order, she would notify the RCM or DNS and they would reach out to the provider for a possible substitute, and the Administrator and DNS stated they would have expected the provider to be notified of the medication being unavailable and of the missed doses. The surveyors determined that the facility’s failure to follow the physician’s order for thyroid medication placed residents at risk for unmet medication needs.
Failure to Implement Airborne Precautions for TB Evaluation
Penalty
Summary
The facility failed to implement airborne precautions for a resident who was being evaluated for tuberculosis (TB). The resident was admitted with a history of cerebral infarction and, following a physician's order, received a TB test and subsequently had a chest x-ray ordered to rule out TB. An order for airborne precautions, including the use of N95 masks and keeping the resident's room door closed, was issued. However, the resident continued to participate in physical therapy and group sessions in communal areas without wearing a mask, and staff did not consistently use personal protective equipment (PPE) when entering the resident's room. The airborne precaution sign on the resident's door was handwritten and did not provide full instructions, and the door to the shared room was often left open with other residents present. Multiple staff members, including CNAs and LPNs, reported entering the resident's room and assisting the resident without PPE, and were unaware of any specialized infection control practices required. The resident confirmed that staff did not consistently wear PPE and that they were not instructed to wear PPE or sanitize hands when outside the room or during therapy. The Director of Nursing Services acknowledged that the airborne precautions were not fully implemented as required, and that staff were expected to follow these precautions until the chest x-ray results were received.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping. The incident occurred when a CNA heard the cognitively intact resident yelling and entered the room to find the confused resident holding the catheter urine collection bag, which had been forcibly removed. The resident who experienced the abuse reported severe pain during and after the incident, and staff interviews confirmed the resident was in significant distress for several days following the event. The facility's abuse policy defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, and requires residents to be protected from such abuse. Multiple staff members recalled the incident, describing the resident's pain and emotional distress, and noted that the resident with dementia was confused at the time. The incident report and staff interviews confirmed that the resident's catheter tubing was broken off during the event, causing ongoing pain and requiring staff support until the resident received pain medication.
Inaccurate Medication Records for Resident Receiving Tramadol
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident with a diagnosis of Parkinson's disease. Upon review, discrepancies were found between the resident's Medication Administration Record (MAR) and the facility's narcotic logbook regarding the administration of Tramadol. The MAR indicated the resident received one dose on two separate days, while the narcotic logbook documented two doses on one day and one dose on the following day. Additionally, a family member reported being told the resident received a dose on a different day not reflected in the MAR. Interviews with multiple LPNs and the Director of Nursing Services confirmed the inconsistency between the records and acknowledged that the MAR and narcotic logbook should match, but staff could not recall specifics about the resident or the medication administration events.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days per week, for four out of 68 days reviewed for staffing. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for Quarter 4, which revealed that on specific dates in July, August, and September 2024, RN coverage was not available for the required duration. Additionally, the Direct Care Staff Daily Reports from December 13, 2024, through January 13, 2025, indicated a similar lack of RN coverage on December 22, 2024. Interviews with the Staffing Coordinator and the Executive Director confirmed the absence of RN coverage on the identified days, acknowledging the facility's failure to meet the required staffing levels.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program that effectively identified and addressed quality deficiencies. Specifically, the facility did not initiate a QAPI review concerning issues related to abuse, investigations, timely reporting, and immunizations. This lack of action placed residents at risk of not receiving optimal care and services. The facility's QAPI policy, last reviewed in May 2023, emphasized a data-driven and proactive approach to quality improvement, yet the Executive Director did not ensure the QAPI plan was reviewed annually by the Quality Assessment and Assurance (QAA) committee. During an interview, the Director of Nursing Services (DNS) and the Regional Director of Clinical Operations confirmed the absence of a QAPI program addressing these concerns.
Lack of Effective QAA Systems in Facility
Penalty
Summary
The facility failed to implement effective systems for identifying problems and taking action to improve and monitor performance, as evidenced by the lack of procedures related to problem identification, analysis, performance improvement, and monitoring in their Quality Assessment and Assurance (QAA) records for 2024. The facility's Quality Assurance and Performance Improvement (QAPI) Plan included oversight of various services and processes, but there was no evidence of enacted procedures for systematic analysis and performance improvement. This deficiency was acknowledged by the Director of Nursing Services (DNS) and the Regional Director of Clinical Operations, placing residents at risk for worsening care.
Inaccessible State Survey Results
Penalty
Summary
The facility failed to ensure that the state survey inspection results were readily accessible to residents and the public. Observations on multiple dates revealed that the notice of survey results was placed approximately five feet high on the wall near the front entrance, making it difficult for individuals in wheelchairs to see. Additionally, the state survey binder, which was supposed to be in a basket below the notice, was missing. During a resident council interview, seven residents indicated they were unaware of where to find the state survey inspection results. The Executive Director confirmed that the survey binders were located on a shelf behind the nurses' station, about six feet high, further limiting accessibility for residents in wheelchairs.
Expired Medications Found in Storage Room and Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication storage room and medication carts, as observed during a survey. In the medication storage room, expired medications including Latanoprost eyedrops, Zioptan eyedrops, and Cephazolin vials were found. Staff 26, a Certified Medication Aide (CMA), confirmed the presence of these expired medications and acknowledged that the facility policy required their removal. However, the expired medications were not separated from other medications as per the facility's policy. Additionally, expired medications were found on multiple medication carts. On the Hall B medication cart, expired MiraLAX and Lispro insulin were identified, with Staff 27, another CMA, uncertain about the facility's policy but aware of the expectation to remove expired medications. On the Hall A room one to five medication cart, expired mucus relief medication was found, with Staff 28, an LPN, also unsure about the policy but aware of the expectation to remove expired medications. Furthermore, the treatment cart for Hall A and C contained expired hemorrhoid cream, Miconazole 7 cream, and triple antibiotic ointment, with Staff 29, an RN, unsure of the policy but aware of the expectation to reorder and remove expired medications. The Director of Nursing Services (DNS) confirmed that the facility's medication storage policy required regular checks and removal of expired medications by all nursing staff.
Failure to Monitor Dishwasher Temperatures During Influenza Outbreak
Penalty
Summary
The facility failed to ensure that dishwasher temperatures were monitored daily during an influenza outbreak, which placed residents at risk for communicable diseases and un-sanitized dishware and utensils. On January 12, 2025, it was observed that the temperature log for the low-temperature dishwasher in the kitchen had multiple blanks for the month and year, with missing entries for wash, rinse, and parts per million (PPM) measurements on several dates. Staff 39, a cook, confirmed that the logs were supposed to be filled out daily but were not. Staff 35, a dietary aide, confirmed that the missing entries were for January 2025 and stated that the logs were to be completed daily. He mentioned that when the dishwasher was not working, the three-sink method was used, but the dishwasher had been operational during his shifts in the last week. The dietary manager, Staff 37, stated that all kitchen staff were in-serviced on December 24, 2024, and were expected to fill in the logs. The executive director, Staff 1, confirmed the in-service training but provided no additional information.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and complete a comprehensive facility-wide assessment, which is crucial for determining the necessary resources to care for residents competently during both day-to-day operations and emergencies. The assessment provided by the facility was found lacking in several critical areas. It did not include a listing of contracts, memorandums of understanding, and other agreements with third parties who provide services or equipment to the facility during normal operations and emergencies. Additionally, there was no facility-based and community-based risk assessment identified in the plan, nor was there an assessment or plan to address continuity of care during an emergency. Furthermore, the assessment failed to consider the care required by the resident population using evidence-based, data-driven methods. This includes evaluating the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts present within the population. The assessment also did not evaluate any ethnic, cultural, or religious factors that may affect the care provided by the facility. Additionally, it lacked infection control-specific information related to current standards, evaluation of services related to communicable diseases, and a plan to ensure timely immunizations. Staff acknowledged the deficiencies in the assessment, and no additional information was provided to address these gaps.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which is a legal document where disputes are resolved with a neutral party rather than in court. This deficiency was identified in three residents who were cognitively intact and had signed the facility's Voluntary Arbitration Agreement form upon admission. Despite the Business Office Manager's assertion that the form was explained to residents and that she was available to answer questions, the residents either did not remember signing the form or did not understand what arbitration meant. Resident 44, admitted with fibromyalgia and asthma, remembered signing a lot of paperwork but not the arbitration agreement. Resident 201, with fibromyalgia and COPD, believed their daughter signed all the paperwork and did not know what arbitration was. Resident 300, admitted with diabetes and a skin infection, also did not remember signing the arbitration agreement and did not understand its meaning. These findings indicate that the facility did not adequately ensure that residents were informed of their legal rights regarding arbitration agreements.
Failure to Offer Influenza Vaccines to Residents
Penalty
Summary
The facility failed to ensure that influenza vaccines were offered to two residents, placing them at risk for respiratory infections. Resident 8, who was admitted in 2014 with diagnoses including traumatic brain injury and contractures, had a consent form signed by their representative on 9/25/23 to receive the influenza vaccine annually. However, there was no documentation in Resident 8's clinical record indicating that the influenza vaccine was offered or received in 2024. Interviews with staff revealed that annual consents should be completed at a resident's care conference, and it was the responsibility of the Director of Nursing Services (DNS) to ensure they were completed yearly. Resident 301, admitted in December 2024 with chronic obstructive pulmonary disease, also did not have documentation of receiving or being offered the influenza vaccine in 2024. The last recorded influenza vaccine for Resident 301 was on 10/3/23. Interviews with staff indicated that vaccine consents are expected to be obtained upon admission, but there were difficulties with agency staff not completing them. This lack of documentation and follow-through on vaccine consents contributed to the deficiency identified by the surveyors.
Failure to Provide COVID-19 Vaccine Information to Residents
Penalty
Summary
The facility failed to ensure that residents received information about the risks and benefits of the COVID-19 vaccine, as required by their policy. This deficiency was identified for two residents. Resident 8, who was admitted in 2014 with a traumatic brain injury and contractures, had a representative refuse the COVID-19 vaccination in September 2023. However, there was no documentation in the resident's clinical record indicating that the risks and benefits of the vaccine were offered or received in 2024. Interviews with staff revealed that annual consents should be completed at a resident's care conference, and it was the responsibility of the Director of Nursing Services (DNS) to ensure they were completed yearly. Resident 301, admitted in December 2024 with chronic obstructive pulmonary disease, also lacked documentation of receiving information about the COVID-19 vaccine's risks and benefits in 2024. The resident's last COVID-19 booster was recorded in December 2022, but no current vaccine consents were found. Staff interviews indicated that obtaining vaccine consents on admission was expected, but there were challenges with agency staff not completing them. This lack of documentation and failure to provide necessary information placed residents at risk of being uninformed about the vaccine.
Shower Room Heater Deficiency
Penalty
Summary
The facility failed to ensure a functional and comfortable environment in one of the three shower rooms reviewed, which placed residents at risk for an uncomfortable bathing experience. On January 12, 2025, a resident reported that the ambient air in the shower room near resident room one was cold during bathing, and the heater in the room could not be used. On January 15, 2025, a State surveyor observed the shower room between rooms one and two and noted that their fingertips became cold after standing there for about 10 minutes. A handwritten sign stating 'DO NOT turn heater on! fire hazard!!' was posted in the shower room. On January 17, 2025, the Executive Director acknowledged awareness of the lack of a heat source in the shower room and confirmed that the heater needed to be replaced.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to implement and document thorough investigations of alleged abuse incidents involving staff and residents. In one instance, an allegation of staff-to-resident physical abuse was reported, but the investigation did not include statements from the alleged perpetrator or a family witness. The staff member involved was terminated due to multiple complaints, but there was no documentation of these complaints or any disciplinary actions in the personnel file. Additionally, there was no evidence of staff training related to abuse following the incident. In another case, an allegation of staff-to-resident physical abuse was reported, but the investigation again lacked a statement from the alleged perpetrator. The staff member was terminated due to multiple complaints, yet there was no documentation of these complaints or any follow-up actions. The facility did not conduct staff training related to abuse after the incident, and there was no tracking system in place to monitor abuse concerns for coordination with the QAPI committee. The facility's failure to conduct root cause analyses or trend tracking for abuse allegations was evident in another reported incident. The investigation did not include a statement from the alleged perpetrator, and the staff member was terminated due to multiple complaints. There were no PIPs in place for abuse, and no abuse audits were completed. The facility lacked a systematic approach to track and address abuse allegations, relying instead on informal methods that were not documented or shared with the QAPI committee.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal and physical abuse within the mandated timeframe for three residents, placing them at risk for further abuse. Resident 19, who was admitted with diagnoses including cirrhosis of the liver, mild cognitive impairment, and obesity, was allegedly verbally abused by a CNA upon arrival at the facility. The incident was witnessed by another CNA and reported to an LPN, but the Facility Reported Incident (FRI) was not submitted to the state agency until three days later. Similarly, Resident 23, admitted with a history of stroke and mild cognitive impairment, reported potential abuse, but the FRI was submitted a day after the incident, missing the two-hour reporting requirement. Resident 202, also with a history of stroke and mild cognitive impairment, experienced potential verbal abuse, but the FRI was submitted three days after the incident. In all cases, the Director of Nursing Services (DNS) confirmed the delays in reporting to the state agency. These delays in reporting allegations of abuse did not meet the required timeframe, which is crucial for ensuring the safety and well-being of residents in the facility.
Incomplete Investigations into Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate alleged physical and verbal abuse incidents involving three residents. For Resident 19, the investigation into alleged verbal abuse by a CNA did not include statements from the accused staff member or the family witness present during the incident. The family member later confirmed that no verbal abuse occurred, and the CNA was not given an opportunity to provide their account before being terminated. Similarly, for Resident 16, the investigation into alleged physical abuse by the same CNA lacked statements from both the accused and the family witness. The family member present during the incident stated that the CNA was not rough and did not act inappropriately. The CNA was again not given a chance to explain the situation before being dismissed from the facility. In the case of Resident 202, the investigation into alleged abuse by a different CNA and an unknown staff member was incomplete, lacking identification of the second staff member and additional statements. The accused CNA was not allowed to provide a statement before being barred from the facility. The facility's documentation was insufficient, with missing or incomplete records, and no abuse audits were conducted following these allegations.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care and treatment as care planned and physician ordered for three residents, leading to delayed treatment and unmet needs. Resident 15, who had a history of cerebral palsy, epilepsy, and phenytoin toxicity, was supposed to have Dilantin levels monitored monthly. However, from April 2024 to July 2024, there was no evidence that the required bloodwork was conducted, despite documentation indicating task completion. This oversight resulted in Resident 15 being hospitalized for Dilantin toxicity in August 2024. Resident 100, admitted with a circulatory disorder and on anticoagulant therapy, had multiple bruises noted upon admission. Despite the care plan requiring monitoring for signs of bleeding, there was no evidence of monitoring for the bruising on the Treatment Administration Record (TAR). Staff interviews revealed a lack of awareness and failure to initiate necessary monitoring orders, leaving the bruising unmonitored. Resident 202, admitted with a history of stroke and mild cognitive impairment, was involved in an alleged abuse incident resulting in an abrasion. The facility's documentation did not include any skin assessment, monitoring, or treatment for the abrasion, nor was there any assessment for psychosocial impact following the incident. Staff acknowledged the expectation for behavior monitoring post-incident, but no evidence of such monitoring was found.
Failure to Provide Timely NOMNC Letters
Penalty
Summary
The facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) letters to a resident, which is a requirement to inform them of their right to appeal the termination of services. Specifically, for one resident, services were scheduled to end on August 9, 2024, but there was no documented evidence that the resident was notified of this termination. This deficiency was confirmed through interviews with the Executive Director and the Social Services Director, who both verified the absence of documentation indicating that the resident was informed of the end of services.
Failure to Address Resident's Dental Needs in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan addressed the dental needs of a resident, who was admitted with chronic obstructive pulmonary disease and dental caries. Despite the resident's cognitive intactness and documented dental issues, including broken and missing teeth, the care plan did not address these needs. Observations during the recertification survey revealed the resident had broken, blackish, and missing teeth, and the resident reported informing staff about the dental issues without any action being taken. Staff interviews confirmed awareness of the resident's dental needs, with a CNA acknowledging a request for a dental visit made months prior, and a Social Services staff member recalling discussions about the dental needs but unsure of documentation. The Regional Director of Clinical Operations provided a dental care plan dated almost a year after admission, confirming the lack of a timely comprehensive care plan. The Resident Care Coordinator acknowledged that a comprehensive dental care plan should have been in place within a month of admission, but it was not established until much later.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident with a traumatic brain injury and contractures, who was always incontinent of both bowel and bladder and required staff assistance with toileting. The resident's care plan required frequent checks and peri care after each incontinent episode, but staff interviews and family member observations indicated that the resident was not always cleaned appropriately. A family member reported that the resident's groin area was not trimmed, leading to feces being left in the area, and a CNA confirmed finding feces in the resident's groin hair during her shifts. Staff members reported that the issue of inadequate cleaning during incontinence care was a problem throughout the facility, with feces not being cleaned from sensitive areas. A peri care spray that could assist in cleaning was not always available, and concerns had been reported to the administration. Despite these reports, the facility's administration was not aware of any current concerns regarding incontinence care, and no grievance had been filed by the family regarding the resident's care.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure prompt routine and emergency dental services for a resident with chronic obstructive pulmonary disease and dental caries. The resident was admitted with broken teeth and no dentures, which affected their ability to chew food. Despite being cognitively intact and having documented dental issues, there was no evidence of a dental appointment or follow-up in the resident's electronic health record. The resident's care plan did not address their dental needs, and staff were aware of the resident's condition but did not ensure timely dental care. Observations revealed the resident had broken, blackish, and missing teeth, causing embarrassment and discomfort. The resident expressed that they informed staff about their dental issues upon admission, but no action was taken for over a year. Staff members, including CNAs and social services, acknowledged the resident's dental needs but failed to document or follow up effectively. A dental appointment was eventually scheduled more than a year after admission, highlighting a significant delay in addressing the resident's dental care needs.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of their medication, specifically Oxycodone, which was brought from home. The resident, who was admitted with arthritis and stroke, had a physician's order for Oxycodone to manage moderate pain. However, discrepancies were found between the medication administration record (MAR) and the narcotic logbook, indicating a mismatch in the number of tablets administered. The resident reported grievances about the untimely administration of their Oxycodone and mentioned that a family member had brought the medication from home due to a delay caused by an ice storm. The medication was reportedly removed from the resident's room by a nurse and was not returned upon the resident's discharge. Despite an investigation being mentioned, no documentation or grievance form was found to address the missing medication. Interviews with staff revealed a lack of clear procedures for handling medications brought from home. The Director of Nursing Services (DNS) and the Administrator acknowledged the issue but could not recall the investigation's outcome. The facility lacked a policy for removing medications from a resident's room, and there was no evidence that the resident's medication was stored or logged appropriately, leading to the misappropriation of the resident's belongings.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for a resident admitted with lupus, depression, and obesity. The resident, who was cognitively intact, expressed a desire to exercise to gain strength for discharge but was not provided with any exercise opportunities or equipment. The resident's health records showed no indication of receiving restorative services, and staff confirmed that the facility did not offer such services due to insufficient staffing. The administrator acknowledged the lack of restorative services and the need to maintain residents' physical strength.
Failure to Provide Discharge Notification
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and did not notify the resident's representative of the discharge. The resident, who was admitted with diagnoses including encephalopathy and dementia, was discharged without receiving the required written notification. On the day of the discharge, neither the resident nor the resident's representative received any written documentation regarding the discharge. Staff interviews confirmed that the discharge paperwork was not completed or provided to the resident prior to the discharge.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with encephalopathy and dementia. The resident, admitted in September 2024, was identified as a fall risk due to visual and sensory communication issues, including night blindness, hearing loss, and vertigo. The care plan included monitoring changes in cognition, decision-making abilities, recall, and awareness of surroundings. However, on October 30, 2024, the resident was found approximately one mile away from the facility, indicating a lapse in supervision. Interviews with staff revealed that the facility was short-staffed on the day of the incident, with two CNAs missing from the day shift. This staffing shortage was confirmed by the facility's Direct Care Daily Staff Report for October 2024. Staff members reported that the lack of sufficient CNA staff contributed to the resident's elopement, as they were unable to safely monitor residents. The Director of Nursing Services confirmed these findings, acknowledging that the staffing issue played a role in the resident's unsupervised departure from the facility.
Latest citations in Oregon
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
