South Hills Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1166 E. 28th Avenue, Eugene, Oregon 97403
- CMS Provider Number
- 385167
- Inspections on file
- 26
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at South Hills Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure a safe, clean, and homelike environment in a first-floor shower room. Surveyors observed broken floor tiles with missing pieces, with several holes containing black sludge-like material and standing water, and another hole filled with gravel and rocks. They also noted multiple holes in the shower wall near the soap dispenser and black discoloration on the caulking, including a larger discolored area in one corner of the shower and other random areas of caulking with similar black coloring. These environmental issues were present in a shower area used by residents and were acknowledged by facility leadership during the survey.
Surveyors found that the facility failed to ensure meals were palatable and acceptable to residents. Multiple residents described the food as horrible, awful, or pretty terrible, with some refusing trays because they could not stand to eat the meals. CNAs reported frequent complaints about the taste and quality of the food, including concerns that it was rotten and too tough to cut. The kitchen manager acknowledged receiving complaints about palatability and noted increased concerns about meals prepared by a particular cook. A sampled lunch tray of pork sausage, buttered noodles, cooked spinach, and spiced peaches was tasted by surveyors and determined to be bland and unpalatable, and the administrator agreed that parts of the meal were bland.
The facility failed to complete ordered skin assessments for a resident with malnutrition and a history of skin tears and did not follow physician orders for medication administration for two other residents. One resident’s documented skin tears were not followed by comprehensive skin assessments. Another insulin‑dependent resident received an extra insulin dose when an RN, relying on incomplete documentation, administered insulin a second time. A third resident with chronic pain and anxiety received higher‑than‑ordered evening doses of methadone and PRN clonazepam doses that exceeded the prescribed 24‑hour maximum, as confirmed by facility leadership.
The facility failed to follow provider orders and accurately administer medications for three residents. A resident with fractures and kidney disease had a critical low RBC lab; the provider ordered ED transfer after a virtual assessment, but the LPN did not enter or act on the order, did not document it at the time, and the oncoming LPN, despite hearing the ED instruction and later being told of low BP and other concerning symptoms, did not verify or complete the transfer or assess the resident. Separately, a resident with sepsis was ordered Cefazolin q8h, but the order was transcribed as ceftriaxone, leading to 11 doses of the wrong antibiotic, and another resident with PTSD had quetiapine orders changed to 300 mg HS with the AM dose discontinued, yet the AM dose continued to be given, resulting in administration of more quetiapine than ordered.
A resident with diabetes and kidney complications did not receive prescribed insulin glargine on multiple occasions when absent from the facility for dialysis. An LPN was unaware if the medication was administered or sent with the resident, and there was no documented clinical plan for insulin administration during these absences.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as ordered by the physician, resulting in low oxygen saturation until staff discovered the oxygen concentrator was off and restored therapy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not provide adequate CNA staffing on multiple shifts over a one-month period, as confirmed by the Regional Staffing Coordinator, placing residents at risk for unmet needs.
Two kitchen staff failed to follow proper hand washing procedures during food preparation and service, including handling items after contact with dirty surfaces and using the same paper towel to turn off the faucet and dry hands. These actions were confirmed by the dietary manager and placed residents at risk for foodborne illness.
A resident with COPD and muscle weakness was found with two inhalers at the bedside without documentation of assessment or authorization for self-administration. Staff were aware of the inhalers but could not confirm if the resident had been properly assessed, and the inhalers remained in the room without an order or evaluation.
A resident with acute kidney disease and intact cognition developed draining blisters and reported severe discomfort, leading to transfer to the emergency department. Nursing staff documented the symptoms but did not notify the physician of the change in condition prior to the transfer, a lapse confirmed by facility leadership.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were subjected to repeated verbal abuse involving racial and discriminatory remarks from other residents. Staff failed to intervene appropriately, often advising the affected residents to ignore the comments or avoid the perpetrator, and did not document or report the incidents as required by policy. Facility leadership confirmed awareness of the abuse but did not provide evidence of timely investigation or reporting.
Two residents who were transferred to the hospital did not receive required written notification of the Bed Hold Policy or transfer notice, despite being cognitively intact. Staff and leadership confirmed that the necessary documentation and notifications were not provided at the time of transfer, and the events were not properly recorded in the clinical records.
A resident with a history of stroke, fluency disorder, and depression was admitted and had a physician order for a CBC lab documented in the psychiatric admission note. The medical record showed the CBC was not obtained, and the DNS confirmed unawareness of the order and that the lab was not completed.
A resident with a history of stroke was found on the floor after an unwitnessed fall, and only one neurological assessment was documented despite facility protocol requiring multiple checks. Staff interviews confirmed that expected neurological assessments were not completed or documented.
A facility's exterior refuse container was observed with its lid open, leaving a significant gap, because staff were unable to close it due to a broken cranking mechanism. The Dietary Manager confirmed that staff did not always close the dumpster for this reason.
The facility failed to provide adequate staffing, resulting in unmet needs for residents, including delayed responses to call lights, missed showers, and increased falls. A resident with paraplegia reported long wait times for assistance, while another resident experienced an incontinent episode due to delayed staff response. Staff consistently reported being overburdened, leading to incomplete care tasks and burnout.
The facility failed to maintain accurate and complete staffing information, with discrepancies noted in the Direct Care Staff Daily Reports and time sheets over July and August 2024. Missing census documentation and inconsistencies in reported CNA hours were observed. Further issues were identified in October 2024, with unposted and incomplete DCSDRs. Facility leadership acknowledged the need for additional education for new nursing staff.
A resident with a chronic ulcer and sacrum fracture reported verbal abuse by a CNA, who allegedly raised his voice and called the resident a liar multiple times. The resident, who was cognitively intact, felt verbally abused and reported the incident. The facility's investigation found the allegations unsubstantiated, but noted the CNA should have left the room and reported the situation.
The facility failed to report investigations timely to the State Survey Agency for three residents reviewed for medications, abuse, and neglect. A resident with anxiety and a leg fracture had an incident reported on time, but the investigation report was delayed due to a misunderstanding by the DNS. Another resident with pain and surgical aftercare had an incident reported late, and the investigation report was delayed due to witness contact issues. A third resident with a leg fracture had an incident reported on time, but the investigation report was sent late.
The facility failed to conduct timely and thorough investigations for three residents, leading to potential risks. A resident with arthritis experienced a fall, but the investigation was delayed. Another resident filed a grievance about rough care, but the investigation lacked witness statements and did not address pain medication. A third resident was found unresponsive after medication, but the investigation did not reconcile medications or review narcotic administration. These deficiencies were confirmed by facility staff.
A CNA in an LTC facility engaged in unprofessional conduct with a resident admitted for a leg fracture. The CNA spent excessive time with the resident, massaged her/his hip inappropriately, and provided personal contact information for future caregiving services. This behavior was reported by the resident and a family member, and confirmed by facility staff, as it violated facility policy and constituted a conflict of interest.
Two residents with cognitive impairments did not receive necessary assistance with ADLs due to staffing issues. One resident went without bathing for extended periods, while another experienced incontinent episodes due to delayed assistance. Documentation inconsistencies and staffing shortages were noted.
A facility failed to maintain accurate records for controlled medications, specifically oxycodone, for a resident with a leg fracture. The resident was administered incorrect dosages and frequencies, and discrepancies were found between the Narcotic Logbook and the Medication Administration Record. Staff acknowledged using the same logbook page despite changes in physician orders, leading to incomplete records and potential medication errors.
The facility failed to address resident dining concerns timely, as evidenced by unresolved issues with outdated menus and the lack of weekly menu availability. Despite initial responses, these concerns were not resolved, and staff acknowledged the oversight.
The facility failed to deliver mail on Saturdays for about a month due to the absence of an activity assistant, as confirmed by a resident and the Activity Director during a Resident Council meeting.
The facility failed to ensure past survey results were readily available for residents and visitors. Residents were unaware of the location of the survey results, which were found obscured by unrelated forms in a wall-mounted bin labeled 'Requests, concerns, and suggestions.' The Administrator confirmed this as the usual location for the survey results.
The facility failed to adequately monitor psychotropic medications for a resident with bipolar disorder and other conditions. Staff did not consistently document monitoring for adverse reactions, missing numerous opportunities in February and March 2024, which placed the resident at risk for ineffective medication management.
The facility failed to ensure waste was properly contained in the garbage storage area, which was observed to be dirty and disorganized with an open garbage container lid and surrounding debris. Staff acknowledged the state of the area and cited a lack of time to clean it, while another staff member was unaware of any requirement to monitor the area.
The facility failed to address resident choice for dining, affecting five residents. Observations and interviews revealed that daily menus were posted but not easily accessible, and residents expressed dissatisfaction with the lack of meal choices. Staff confirmed the absence of printed menus and acknowledged residents' concerns.
The facility failed to provide adequate supervision and care to prevent accidents for four residents. One resident with dysphagia was left unsupervised during meals, another with severe cognitive impairment eloped twice, a third resident at risk for falls experienced two unwitnessed falls, and a fourth resident with a history of noncompliance with the smoking policy was improperly assessed as an unsupervised smoker.
The facility failed to provide adequate staffing, resulting in prolonged call light wait times and residents experiencing incontinence due to delays in assistance. Multiple residents and staff reported significant delays, with some residents left in soiled conditions or on commodes for extended periods. The facility acknowledged the staffing issues and stated they were actively hiring.
The facility failed to staff an RN for 8 consecutive hours per day, 7 days per week, for 15 out of 123 days reviewed, placing residents at risk for unmet assessment needs. The issue was acknowledged by the facility's administrative and regional staff, who stated they were actively hiring to address the deficiency.
The facility failed to complete annual performance reviews for five CNAs hired between December 2013 and December 2021, as confirmed by the Administrator. This placed residents at risk for receiving care from potentially incompetent staff.
The facility failed to submit mandatory staffing information based on payroll data and other verifiable and auditable data as required by CMS. During an interview, the Administrator, DNS, and other regional directors stated that the corporate office was responsible for submitting the data and they were unaware that it had not been submitted.
The facility failed to follow infection control standards for a resident with a catheter and for handling dirty linens. A resident's catheter bag was improperly attached and in contact with the floor, and a CNA was observed carrying dirty linens without using disposable bags, despite their availability.
The facility failed to assess two residents for self-administration of medications. One resident with kidney disease was not assessed for self-administration of a phosphorous binder, and staff did not administer the medication with meals as required. Another resident with diabetes was found to have medicated cream at their bedside without an assessment for self-administration.
The facility failed to address a resident's missing items timely. Despite reports from the resident's family member about a missing shirt and blanket, no resolution was provided, and no grievance forms were filled out. The staff did not follow the protocol of documenting missing items and responding within seven days.
The facility failed to monitor and assess the continued use of a physical restraint for a resident with muscle wasting and atrophy, who was identified as an elopement risk due to dementia and wandering behavior. Despite documentation inconsistencies and a request to discontinue the Wander Guard, it remained in place, triggering an alarm when the resident was taken out for an appointment. This placed the resident at risk for potential abuse or neglect.
The facility failed to conduct a Significant Change MDS assessment within the required timeframe for a resident admitted to hospice care. The resident, diagnosed with heart disease, was approved for hospice services, but the significant change MDS was not completed within 14 days. The MDS Coordinator acknowledged this oversight.
The facility failed to revise care plans for three residents, including one with changed dialysis times, another admitted to hospice, and a third experiencing pain from hemorrhoids. Staff acknowledged the care plans were not updated to reflect the residents' current needs.
A facility failed to provide elbow braces for a resident with contractures, despite the care plan indicating the need for braces during the day. The braces were inconsistently offered, and staff were unaware of the requirement, leading to compromised mobility and pain for the resident.
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, leading to an increased risk of infections. Despite a care plan and a urology clinic note indicating the need for a follow-up appointment and catheter change, the facility did not schedule the necessary follow-up. Additionally, the facility lacked the appropriate supplies to perform the catheter change, further delaying the necessary care.
The facility failed to maintain healthy nutritional parameters for a resident with dysphagia, leading to unsupervised meals, inconsistent care plans, and discontinued nutritional supplements without proper documentation. Staff interviews revealed reliance on verbal reports and unclear physician orders, placing the resident at risk for further weight loss.
A resident with hemorrhoid pain did not receive timely pain management interventions, including prescribed witch hazel pads and a specialized cushion, due to lapses in communication and failure to update the care plan. This resulted in ongoing pain and decreased activity levels.
The facility failed to address pharmacy recommendations for a resident with arthritis and anxiety. A pharmacy review recommended labs to evaluate medications, but there was no evidence the labs were obtained. This was confirmed by the Staff Development Coordinator, indicating the labs were not obtained timely.
The facility failed to obtain routine labs to monitor the effectiveness of medications for a resident. A pharmacy review identified the need for labs to evaluate medications for high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. Although the labs were ordered by the physician, they were not obtained until a later date, as confirmed by the Staff Development Coordinator.
A resident with a history of stroke and abnormal weight loss had a colonoscopy canceled due to refusal to consume preparation medication. The physician was notified, but this was not documented, and the test was not rescheduled, leading to a delay in treatment.
A resident with malnutrition and quadriplegia had her/his teeth extracted and required dentures. Despite a care plan revision and repeated requests, the resident did not receive dentures. The social worker tried to arrange an appointment but was waiting for the DNS to discuss the procedure's risks and benefits. The DNS admitted that follow-up was lacking.
Failure to Maintain Safe and Clean Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in a first-floor shower room on one of two halls reviewed for environment. During an observation with the Administrator, surveyors identified four broken tiles with missing pieces on the shower floor, with three of the resulting holes containing a black sludge-like substance and standing water, and a fourth hole near the shower entrance filled with gravel and rocks of various sizes. Additional environmental deficiencies included four holes in the shower wall near the soap dispenser and areas of black discoloration on the caulking, including a corner of the shower where the black coloring extended approximately four to five inches vertically and about two inches horizontally, as well as other random areas of caulking with similar black coloring. These conditions were directly observed in the shower room used by residents and were acknowledged by the Administrator at the time of the survey, demonstrating that the facility had not ensured the shower environment was properly maintained to meet standards for safety, cleanliness, and homelikeness.
Failure to Provide Palatable and Acceptable Meals
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure food was palatable, as required for safe and appetizing meals. During resident interviews, one resident stated the food was horrible and that many residents refused their trays because they could not stand to eat it, another resident described the food as pretty terrible, and a third resident called the food awful. Multiple CNAs reported that residents had complained about the taste of the food, with one CNA stating the food was horrible, rotten, and usually too tough for residents to cut. The Kitchen Manager acknowledged she occasionally received complaints about food palatability and noted increased complaints related to meals prepared by the cook for that day’s lunch. A sample lunch tray consisting of pork sausage, noodles with butter, cooked spinach, and spiced peaches was tasted by surveyors and found to be bland and unpalatable, and the Administrator acknowledged that the noodles and spinach were bland. These observations and interviews showed that both residents and staff consistently reported poor taste and quality of the food, and that a sampled meal was directly assessed as bland and unpalatable, demonstrating the facility’s failure to provide palatable meals.
Failure to Complete Skin Assessments and Follow Physician Medication Orders
Penalty
Summary
The facility failed to complete required skin assessments and evaluations for a resident with known risk factors and a history of skin tears, and failed to follow physician orders for medication administration for two residents. One resident, admitted with malnutrition and care-planned for potential skin integrity impairment and a history of skin tears, had documented skin tears to the left elbow and right hand on two separate dates. However, the clinical record contained no documented evidence that comprehensive skin assessments or evaluations were completed for these wounds, a fact later verified by the DNS. The facility also failed to follow physician orders for insulin and controlled medications for two other residents. One insulin‑dependent resident received an extra dose of insulin when an RN, seeing insulin due and lacking completed documentation from the prior nurse, administered a second dose; the resident confirmed receiving a second insulin dose, and administration was acknowledged as not in accordance with physician orders. Another resident with bilateral knee osteoarthritis and anxiety disorder had physician orders for methadone with a lower evening dose and PRN clonazepam not to exceed three tablets in 24 hours. Medication error forms documented that this resident was given a higher methadone dose than ordered for the evening dose on two occasions and was administered four clonazepam tablets on two separate dates, exceeding the ordered 24‑hour maximum. These errors were acknowledged by facility leadership.
Failure to Follow Provider Orders for ED Transfer and Accurate Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and properly act on critical lab values and medication orders for three residents. For one resident with multiple spinal fractures and kidney disease, a critical low red blood cell count was reported to the facility, and the on‑call physician conducted a virtual assessment and ordered the resident sent to the ED via non‑emergent transport for possible blood transfusion. The LPN who received the critical lab and the order did not enter the ED transfer order into the chart, did not act on the transport order, and did not document the provider’s verbal order at the time. She instead wrote a note the following day. Another LPN coming on to the next shift overheard the provider instructing that the resident be sent to the ED and that family be called, but she was not informed of the critical lab or the need to complete the transfer and assumed, without confirming, that the resident had refused transfer. During the evening, the second LPN administered nausea medication twice and was informed by a certified occupational therapy assistant that the resident had low blood pressure, changes in cognition, increased fatigue, nausea, and pale skin. The LPN instructed the assistant to give the resident water and retake the blood pressure, and when the repeat blood pressure was reported, she stated she was no longer concerned and did not assess the resident despite the reported symptoms. The resident remained in the room and was not sent to the ED as ordered. A subsequent progress note documented that the resident died early the next morning. The Director of Nursing Services later acknowledged that the nurse who received the critical lab did not write a timely progress note, did not enter the verbal order to transport the resident to the ED, did not act on the transport order, and did not document the provider’s verbal order at the time of the incident. The deficiency also includes two separate medication error issues. One resident admitted with sepsis had a physician order for Cefazolin every eight hours, but the order was transcribed as ceftriaxone, and the resident received the wrong antibiotic 11 times, as documented in the MAR and a facility report of incident. Another resident with PTSD had a physician order for quetiapine 100 mg in the morning and at bedtime; during a care conference for gradual dose reduction, it was noted that the resident had been administered more quetiapine than ordered. The orders were changed to 300 mg at bedtime with discontinuation of the 100 mg morning dose, but the morning dose was not discontinued, resulting in continued administration beyond the revised order. The DNS acknowledged the medication administration errors for both residents.
Failure to Administer Insulin per Physician Orders During Resident Absence
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes and diabetic kidney complications who was admitted in July 2025. Physician orders dated September 2025 directed staff to administer insulin glargine twice daily for diabetes management. Documentation showed that during five morning medication administrations, the resident was absent from the facility without her/his medications. Staff interviews revealed that the resident left the facility before the morning shift began to attend dialysis and returned in the afternoon. The LPN responsible for the morning shift was unaware of whether the night nurse had administered the insulin or if it was sent with the resident to dialysis. The regional nurse confirmed that physician involvement would be expected in developing a clinical plan for insulin administration while the resident was out of the facility.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with chronic respiratory failure. The resident was admitted with a physician's order for continuous oxygen at three liters per minute every shift. On one occasion, a physical therapist assistant entered the resident's room and found the oxygen concentrator was not turned on, resulting in the resident's oxygen saturation dropping to 88 percent. After oxygen was administered, the saturation increased to 93 percent. Staff confirmed that the oxygen concentrator had been off when the resident was found, and the administrator acknowledged that staff were expected to follow physician orders for oxygen use. A public complaint was also received alleging that after the resident was returned to their room, staff did not turn on the oxygen concentrator, and it remained off for several hours until discovered by staff.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify the exact actions or inactions, nor does it provide details about the residents or staff involved, but it clearly states the absence or inadequacy of an infection prevention and control program.
Failure to Maintain Sufficient CNA Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of every resident, as required. Review of the Direct Care Staffing Daily Report forms for the period from 7/1/25 through 8/3/25 showed that the facility did not have sufficient CNA staffing on six out of thirty-three days. Specifically, insufficient staffing was noted on the day shift for 7/3/25, the evening shift for 7/4/25, and the night shifts for 7/22/25, 7/5/25, 7/8/25, and 7/19/25. This was confirmed by the Regional Staffing Coordinator during an interview on 5/9/25 at 9:09 AM. Residents were placed at risk for unmet needs due to these staffing shortages. No additional details about individual residents or their medical conditions were provided in the report.
Improper Hand Hygiene Observed During Food Service
Penalty
Summary
Staff failed to properly follow hand hygiene protocols during food preparation and service. Specifically, one dietary aide was observed handling a plate cover that had been placed on a dirty dish counter and then returning to plating lunches without washing his hands. On multiple occasions, staff washed their hands but then either turned off the faucet with wet hands or used the same paper towel to both turn off the faucet and dry their hands, which is not in accordance with proper hand washing procedures. The corporate dietary manager confirmed that the observed staff did not follow the correct hand washing procedure during lunch preparation. These actions were directly observed by surveyors and involved two of three kitchen staff, placing residents at risk for foodborne illness due to improper hand hygiene during food service.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness was found to have two inhalers at their bedside without documentation of an assessment for safe self-administration of medication. The resident stated that staff were aware of the inhalers in the room and explained that they used the inhaler during COPD flare-ups, expressing concern about delays if they had to wait for staff assistance. Observation confirmed the presence of both inhalers, and staff interviews revealed uncertainty regarding whether the resident was authorized or assessed to self-administer these medications. A CNA reported the presence of the inhalers to the charge nurse but was unaware of any authorization for self-administration. An LPN confirmed knowledge of the requirement for assessment prior to residents keeping medications at the bedside but did not know if this had occurred for the resident in question. The LPN checked the inhalers and left them in the room, stating he would follow up with administration. The Corporate Director of Nursing Services later acknowledged that the resident did not have an order or assessment for self-administration of inhalers.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
Facility staff failed to notify a physician of a change in condition for a resident who was admitted with acute kidney disease and was cognitively intact, as indicated by a BIMS score of 14. On the evening in question, nursing notes documented that the resident developed draining blisters on the chest and reported sensations of burning and being stabbed with needles. The resident was subsequently sent to the emergency department. However, a review of the medical record confirmed that the physician was not notified of these changes in the resident's condition prior to the transfer. This lack of physician notification was acknowledged by the Corporate DNS, DON, and Regional nurse during interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent and Report Verbal Abuse Among Residents
Penalty
Summary
The facility failed to prevent and properly report verbal abuse for two residents who were subjected to repeated racial and discriminatory remarks by other residents. One resident, admitted with respiratory failure and cognitively intact, experienced multiple incidents where another resident made derogatory comments about their language and ethnicity in the presence of staff, family, and other residents. Despite these repeated outbursts, staff responses were limited to apologizing to the affected resident and advising them to avoid the perpetrator or ignore the comments, rather than intervening or addressing the abusive behavior. No documentation of an internal investigation or facility-reported incident was provided for these events, and staff did not report the incidents to the appropriate authorities as required by facility policy. Another resident, with dementia and anxiety, reported being subjected to a racial slur by a former roommate following an argument. This incident led the resident to avoid communal areas due to discomfort and fear of further interaction. Again, the facility did not provide any documentation of an investigation or facility-reported incident related to this verbal abuse. Interviews with facility leadership confirmed awareness of the incidents but revealed no evidence of timely reporting or investigation, as required by the facility's abuse policy.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to inform two cognitively intact residents of the Bed Hold Policy when they were transferred to the hospital. For one resident with Type 2 diabetes mellitus, staff responded to a medical emergency involving a fall and low blood glucose, resulting in the resident being transported to the hospital by EMS. There was no documentation that the resident or their representative received a copy of the Bed Hold Policy or written notice of transfer, as required by facility policy. Staff interviews confirmed that the process was not followed, with some staff stating that only verbal offers were made or that paperwork was not provided at the time of transfer. A second resident, admitted with acute kidney disease, was also transferred to the hospital after developing severe symptoms, including blisters and pain. Review of the clinical record found no documentation that the resident was informed of the Bed Hold Policy or received written notice of transfer. Facility leadership confirmed that the required notices were not given in either case, and staff acknowledged the oversight in providing discharge and treatment notices.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to follow physician orders for laboratory testing for a resident admitted with a history of stroke, fluency disorder, and depression. A psychiatric admission progress note documented a new order for a Complete Blood Count (CBC) lab for the resident. However, review of the resident's medical record showed no evidence that the CBC lab was obtained. During an interview, the Director of Nursing Services (DNS) confirmed she was not aware of the laboratory order and acknowledged that it was not completed.
Failure to Complete Required Neurological Checks After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when staff failed to properly monitor a resident after an unwitnessed fall. The resident, who had a history of stroke, was found on the floor next to their bed after their roommate activated the call light. The resident was unable to recall how they ended up on the floor or whether they struck their head. Facility protocol required neurological checks to be performed at specific intervals following an unwitnessed fall, but only one neurological assessment was documented in the clinical record. Interviews with staff confirmed that neurological assessments were expected to be completed and documented, but this was not done for the resident involved.
Failure to Keep Refuse Container Covered Due to Broken Mechanism
Penalty
Summary
During an observation of the facility's outdoor trash and recycling area, the exterior refuse container was found with its lid open, leaving a gap of approximately twelve to fifteen inches between the lid and the body of the dumpster. The Dietary Manager confirmed that staff did not always close the dumpster because it was difficult to close, and when attempting to close it, was unable to do so due to a broken cranking mechanism. This failure to keep the refuse container covered was directly observed and acknowledged by staff during the walkthrough.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple accounts from residents, staff, and witnesses. Resident 17, who was admitted with paraplegia and a pressure ulcer, reported that during August and September, there were instances when their call light was activated for hours without response, particularly on weekends when staffing was critically low. Witnesses and staff corroborated these claims, noting that the facility was often short-staffed, leading to unmet needs such as missed showers and increased falls. Resident 22, who had a history of falling, dementia, and anxiety, experienced an incontinent episode due to delayed staff assistance, as the facility was short-staffed. Documentation revealed that the facility did not meet state minimum CNA staffing requirements on certain shifts, contributing to the resident's unmet needs. Witnesses confirmed that the resident had to wait for assistance, which led to the incontinent episode. Staff members consistently reported that the facility was short-staffed, leading to negative outcomes for residents, including increased falls and missed care tasks. Several staff members, including CNAs and agency staff, described being assigned an excessive number of residents, which made it difficult to provide adequate care. The lack of sufficient staffing resulted in long call light wait times, incomplete care tasks, and staff burnout, further exacerbating the situation.
Inaccurate Staffing Information Posting
Penalty
Summary
The facility failed to post accurate and complete staffing information, as evidenced by multiple discrepancies in the Direct Care Staff Daily Reports (DCSDR) and Daily Punches (staff time sheets) over the months of July and August 2024. Specific issues included missing census documentation for various shifts on several days, incomplete DCSDR entries, and inconsistencies between the reported hours worked by Certified Nursing Assistants (CNAs) and the actual hours documented in the time sheets. For instance, on 8/15/24, the DCSDR indicated that seven CNAs worked a total of 56 hours, whereas the time sheets showed only 39.5 hours worked by six CNAs. Similar discrepancies were noted on 8/28/24. Further observations in October 2024 revealed that the DCSDR for 10/8/24 was not posted, and on 10/9/24, the DCSDR lacked census documentation for the day shift. During an interview on 10/16/24, the facility's Administrator, Director of Nursing Services (DNS), and Regional Nurse Consultant acknowledged the presence of new nursing staff and the need for additional education on completing the DCSDR sheets. These deficiencies in maintaining accurate staffing records placed residents at risk for incomplete and inaccurate staffing information.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident who was admitted with diagnoses including a chronic ulcer and a sacrum fracture. The resident reported that a CNA entered their room loudly, waking them from a deep sleep, and continued to raise his voice during interactions. The CNA allegedly called the resident a liar multiple times and refused to leave the room despite the resident's requests. The resident felt verbally abused and reported the incident to the admissions coordinator, who witnessed the CNA apologizing but still yelling at the resident. The investigation revealed that the resident was cognitively intact, with a BIMS score of 15, and exhibited no behavioral symptoms in the days leading up to the incident. The CNA admitted to calling the resident a liar but denied yelling. The facility's investigation concluded that the allegations were unsubstantiated, although it was noted that the CNA should have left the room and reported the resident's behavior to a charge nurse when the situation escalated.
Delayed Reporting of Investigations to State Agency
Penalty
Summary
The facility failed to report investigations timely to the State Survey Agency for three residents reviewed for medications, abuse, and neglect. Resident 12, admitted with anxiety and a leg fracture, had an incident reported to the State Agency on the same day it was discovered, but the investigation report was sent late. Staff confirmed that the delay was due to a misunderstanding by the Director of Nursing Services (DNS) who thought she had emailed the investigation on time. Resident 19, admitted with pain and surgical aftercare, had an incident reported five days after it occurred, as the facility was only made aware of it on that day. The investigation report was also sent late due to difficulties in contacting a witness. Resident 20, admitted with a leg fracture, had an incident reported on the day it occurred, but the investigation report was again sent late. Staff confirmed the delay in sending the investigation report to the State Agency.
Failure to Conduct Timely and Thorough Investigations
Penalty
Summary
The facility failed to conduct timely or thorough investigations for three residents, leading to potential risks. Resident 11, admitted with arthritis, experienced an unwitnessed fall on 6/3/24, but the investigation was not completed until 6/26/24, which was confirmed as late by the facility's staff. Resident 19, admitted with pain and surgical aftercare, filed a grievance on 6/24/24 regarding rough care by an agency LPN during wound treatment on 6/19/24. The investigation, conducted from 6/24/24 to 7/1/24, did not include witness statements or contact with the LPN involved, and failed to address Resident 19's pain medication, as confirmed by facility staff. Resident 20, admitted with a leg fracture, was found unresponsive after medication administration on 9/27/24. An investigation from 9/27/24 to 10/10/24 revealed a family member's concern about sedation and abuse, but the investigation did not reconcile the resident's medications or review narcotic administration. Facility staff focused on communication with the emergency department rather than the medication issue. The investigation also erroneously included information about an unrelated resident altercation. These deficiencies were confirmed by facility staff, indicating a lack of thoroughness in addressing the medication and care concerns.
Inappropriate Conduct by CNA with Resident
Penalty
Summary
Facility staff failed to adhere to professional standards of practice in the care of a resident, identified as Resident 12, who was admitted with a leg fracture. The deficiency involved Staff 7, a CNA, who engaged in behavior that was deemed inappropriate and unprofessional. Staff 7 was reported to have spent excessive time with Resident 12, massaged her/his hip in a manner that felt inappropriate, and provided personal contact information to the resident, suggesting he could be her/his personal caregiver post-discharge. These actions were reported by Resident 12, who felt uncomfortable with the level of personal attention and the nature of the interactions, although she/he did not categorize it as sexual abuse. The situation was further corroborated by a family member, Witness 7, who confirmed that Staff 7 had offered his contact information for future caregiving services and applied cream to Resident 12 without a request. Staff 36, a Speech Therapist, documented the incident by photographing the contact information and reporting it to Staff 35, the Director of Rehabilitation, who then informed the facility's Administrator. The facility's administration confirmed that Staff 7's actions were against facility policy and constituted a conflict of interest, as it involved soliciting work outside the facility. Despite the resident's modesty and lack of feeling of inappropriate physical contact, the interactions were considered unprofessional and inappropriate by the facility's standards.
Failure to Assist Residents with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to unmet needs. Resident 21, who was admitted with dementia and anxiety, required substantial to maximal assistance with bathing. Despite this, there were multiple instances where Resident 21 did not receive the required bathing assistance, going up to 13 days without a bath. Documentation inconsistencies were noted, with some records indicating refusal without proper resident signatures, and staff misreporting environmental limitations as resident refusals due to a lack of staff. Resident 22, admitted with a history of falling, dementia, and anxiety, was dependent on staff for toilet use and transferring. The facility was short-staffed, leading to delays in assistance and resulting in incontinent episodes for Resident 22, who was otherwise occasionally continent. The facility's staffing levels did not meet state minimum requirements, contributing to the inability to provide timely assistance, as confirmed by staff and a complainant.
Inaccurate Medication Records for Controlled Substances
Penalty
Summary
The facility failed to ensure that resident records related to controlled medications were complete and accurate, specifically for a resident who was admitted with a leg fracture. The review of the Narcotic Logbook (NLB) for September 2024 revealed discrepancies in the administration of oxycodone, a narcotic pain medication, for this resident. The resident was prescribed oxycodone in various dosages and frequencies, but the records showed multiple instances where the resident was administered two tablets instead of the one tablet as ordered by the physician. Additionally, the resident received the medication more frequently than prescribed on several occasions. Further review of the Medication Administration Record (MAR) indicated inconsistencies with the NLB, including missing documentation for certain prescribed dosages and frequencies of oxycodone. The facility staff, including the Administrator, Director of Nursing Services (DNS), and Regional Nurse Consultant, acknowledged that the resident received medications as ordered by the physician, but staff continued to use the same page in the NLB even after changes in the resident's physician orders. This practice led to incomplete and inaccurate medication records, placing residents at risk for medication errors.
Failure to Address Resident Dining Concerns
Penalty
Summary
The facility failed to respond timely to resident concerns related to dining, as evidenced by the Resident Council minutes from November 2023 to March 2024. Residents expressed concerns about outdated 'always available' menus in their rooms and requested weekly menus to make meal choices. Despite the facility's initial responses, these issues were not resolved. By March 2024, the Dietary Manager and Registered Dietitian acknowledged that printed menus were not available due to other dining priorities. The Administrator and Regional Director of Social Services and Activities also acknowledged that residents' concerns should have been addressed in subsequent meetings, but they were not.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to have a system in place to deliver mail on Saturdays, which was identified during a Resident Council meeting. A resident stated that for a long time, residents did not receive mail on Saturdays. The Activity Director confirmed that mail delivery on Saturdays ceased approximately a month ago due to the absence of an activity assistant, who previously handled this task.
Failure to Make Survey Results Readily Available
Penalty
Summary
The facility failed to ensure past survey results were readily available for residents and visitors. During a resident council interview, residents stated they did not know where the past survey results were kept and believed they were at the nurses' station. Upon observation, the past survey results were found in a clear wall-mounted bin labeled 'Requests, concerns, and suggestions,' but were obscured from view by unrelated facility forms such as information regarding rules for visits and grievance forms. The Administrator confirmed this location as the usual place for keeping the survey results.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor psychotropic medications for a resident diagnosed with bipolar disorder with depression, personality disorder, and agoraphobia with panic disorder. The resident was prescribed Duloxetine for mood disorder with depression and Rexuliti for bipolar disorder. A review of the resident's Medication Administration Records (MARs) for February and March 2024 revealed that staff did not consistently monitor for adverse reactions to these medications. Specifically, in February, out of 87 opportunities, staff failed to monitor on 32 occasions, and in March, out of 57 opportunities, staff failed to monitor on 25 occasions. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Staff Development Coordinator, confirmed that they were required to monitor for adverse reactions but did not consistently document this in the resident's medical record. This lack of consistent monitoring and documentation placed the resident at risk for ineffective medication management. The deficiency was identified through both interview and record review, highlighting a significant lapse in the facility's medication monitoring protocols.
Improper Waste Containment in Garbage Storage Area
Penalty
Summary
The facility failed to ensure waste was properly contained in the garbage storage area, which was observed to be dirty and disorganized. On multiple occasions, the garbage container lid was found open, and the surrounding area was littered with broken doors, unused resident commodes, dirty disposable gloves, miscellaneous wood pieces, and outdoor debris. Staff 42 (Maintenance Director) acknowledged the state of the garbage area and cited a lack of time since February 2024 to clean it. Staff 41 (CNA) confirmed that the area frequently had debris, including dirty gloves. Staff 31 (Dietary Manager) was unaware of any requirement to monitor the garbage area but agreed it should be kept clean.
Failure to Address Resident Choice for Dining
Penalty
Summary
The facility failed to address resident choice for dining, affecting five of the 22 sampled residents. Observations revealed that daily menus were posted on the first and second floors, but no weekly menus were available. Several residents expressed dissatisfaction with the lack of meal choices and the new system implemented by the facility, which required a three-hour notice for menu changes. Residents who were bedridden found it difficult to access the posted menus, and some reported that staff no longer discussed daily menu options with them. One resident mentioned that the option to choose between two meal options was no longer available, and another resident, new to the facility, had no choices related to daily meal options and was dissatisfied with the provided meal. Staff interviews further confirmed the deficiency. An LPN was unaware of the accurate menu information and acknowledged that residents frequently voiced concerns about the removal of menu choices. The Dietary Manager and Registered Dietitian admitted that there were no printed menus for residents, making it difficult for them to understand their meal options. Additionally, the Administrator and Northern Regional Director of Operations confirmed that menu information was not included in new admissions packets and acknowledged the need for printed menus to be distributed and placed in every resident room.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent accidents for four residents. Resident 4, who had dysphagia, was left unsupervised during meals despite needing assistance and monitoring to prevent choking. The care plan was not updated, and staff did not follow the necessary interventions, leading to the resident being at risk while eating alone in their room for 20 minutes without supervision. Resident 220, with severe cognitive impairment, eloped from the facility twice in one evening. The first incident was witnessed by staff, and the second was unwitnessed. Despite being found on the facility grounds, the investigation revealed multiple lapses in supervision and failure to secure the facility's perimeter, allowing the resident to leave the building and access unsafe areas. Resident 22, who was at risk for falls, experienced two unwitnessed falls. The investigations into these falls were incomplete, failing to document critical details such as the duration the call light was activated and the last time the resident was visualized. Additionally, the care plan was not followed, and no new interventions were implemented to prevent further falls. Resident 35, who had a history of noncompliance with the facility's smoking policy, was assessed as an unsupervised smoker despite having dexterity problems and a history of hiding smoking materials. The resident was observed smoking unsupervised and improperly disposing of cigarette butts, indicating a failure to reassess and update the smoking risk assessment accurately.
Inadequate Staffing Leading to Prolonged Call Light Wait Times and Incontinence
Penalty
Summary
The facility failed to have adequate staff available to meet the needs of residents in a timely manner, as evidenced by multiple instances of prolonged call light wait times and residents experiencing incontinence due to delays in assistance. Resident 10, who was admitted in 2020 with diagnoses including difficulty in walking and a stroke, reported call light wait times of over 15 minutes, and sometimes over 30 minutes, leading to multiple incontinent episodes. Documentation confirmed Resident 10 was incontinent on two occasions in March 2024. Staff interviews corroborated these findings, with one CNA stating she was often assigned 12 to 13 residents and had to prioritize tasks, resulting in residents waiting 20 to 30 minutes for assistance and being found soaked in urine or soiled with feces at the start of shifts. Resident Council Minutes from November 2023 indicated that staff would deactivate call lights without addressing residents' needs, with wait times as long as an hour. Multiple residents and a family member reported call light wait times ranging from 20 minutes to over an hour, with some residents left in the restroom or on a bedside commode for extended periods. One resident reported not receiving showers due to staff shortages, and another stated they had to clean themselves after an incontinent episode due to the lack of staff assistance. Staff interviews further highlighted the staffing issues, with reports of insufficient CNA staff on day and evening shifts, difficulty in finding assistance for two-person tasks, and incomplete care due to short staffing. One LPN described a situation where only one nurse was available to handle multiple tasks, including medication passes, admissions, wound care, and IV treatments. Another staff member noted that residents were not receiving showers and were left on commodes for extended periods due to staffing shortages. The facility acknowledged the ongoing issue and stated they were actively hiring staff.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for 8 consecutive hours per day, 7 days per week, for 15 out of 123 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports for the periods of 5/1/23 through 5/31/23, 6/1/23 through 6/31/23, 8/1/23 through 8/31/23, and 2/17/24 through 3/17/24. Specifically, the facility lacked RN coverage on the following days: 5/18/23, 5/24/23, 5/30/23, 5/31/23, 6/6/23, 8/1/23, 8/2/23, 8/9/23, 8/15/23, 2/18/24, 2/27/24, 3/3/24, 3/5/24, 3/10/24, and 3/12/24. This placed residents at risk for unmet assessment needs. During an interview on 3/22/24, the facility's administrative and regional staff acknowledged the ongoing issue and stated that they were actively hiring staff to address the deficiency.
Failure to Complete Annual Performance Reviews for CNA Staff
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for five Certified Nursing Assistants (CNAs) who were sampled for staffing. Specifically, the facility was unable to provide performance reviews for CNA staff members hired on various dates ranging from December 2013 to December 2021. This deficiency was confirmed by the Administrator, who acknowledged the absence of performance reviews for these staff members. The lack of documented performance reviews placed residents at risk for receiving care from potentially incompetent staff.
Failure to Submit Mandatory Staffing Information
Penalty
Summary
The facility failed to submit mandatory staffing information based on payroll data and other verifiable and auditable data as required by CMS. This deficiency was identified during a review of the Payroll Based Journal Staffing Data for fiscal year, quarter two, 2023, which indicated that the facility did not submit the required data for the quarter. During an interview, the Administrator, DNS, Regional Director of Social Services and Activities, Regional Director of Clinical, and Northern Regional Director of Operations stated that the corporate office was responsible for submitting the data and they were unaware that it had not been submitted.
Infection Control Deficiencies in Catheter and Linen Handling
Penalty
Summary
The facility failed to follow infection control standards for a resident with a catheter and for handling dirty linens. Resident 4, who was admitted with prostate cancer and had a catheter due to urinary retention, was observed with the catheter bag improperly attached to a small garbage can and later with the catheter bag in contact with the floor while in the dining room. Staff 12, an agency CNA, admitted to attaching the catheter bag to the garbage can due to the bed's low position and lack of knowledge on proper attachment. Facility leadership was informed of these observations but did not take immediate corrective action. Additionally, a CNA was observed carrying dirty linens in her hands instead of using disposable bags, which were reportedly not available since December 2023. Despite the presence of dispensers filled with disposable bags in resident bathrooms, the CNA and a unit manager were unaware of their availability. The unit manager confirmed observing staff handling dirty linens without disposable bags but did not address the issue with the CNA staff. This failure to use proper infection control measures for handling dirty linens further contributed to the deficiency.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed for self-administration of medications, affecting two residents. Resident 13, diagnosed with kidney disease, expressed a desire to self-administer a phosphorous binder but was not assessed for this capability. Despite being cognitively intact and having communicated this wish to staff, no assessment was conducted. Additionally, staff failed to administer the medication with meals as required, instead providing it after meals, which was not in line with the prescribed regimen. Resident 47, diagnosed with diabetes, was found to have a tube of medicated cream on their bedside table, which they applied as needed. However, there was no record of an assessment for self-administration of this medication in the resident's clinical record. Staff confirmed that an assessment, an order for self-administration, a care plan, and secure storage of the medication were required but had not been completed for this resident.
Failure to Address Resident's Missing Items Timely
Penalty
Summary
The facility failed to ensure a resident's missing items were addressed timely for a resident admitted with a diagnosis of heart disease. Approximately one month prior, the resident's family member reported a missing favorite shirt to the laundry staff, and two weeks later, a new blanket went missing. Despite the staff's assurance to look for the items, no resolution was provided. The Regional Director of Clinical confirmed that no missing item forms were filled out for the resident. The Laundry Manager acknowledged receiving a hand-written note about the missing blanket but did not fill out a grievance form and could no longer locate the note. The Northern Regional Director of Operations stated that missing items should be documented on a form and a response provided within seven days, which was not done in this case.
Failure to Monitor and Assess Continued Use of Physical Restraint
Penalty
Summary
The facility failed to monitor and assess the continued use of a physical restraint for Resident 4, who was admitted in 2022 with diagnoses including muscle wasting and atrophy. The care plan revised on 8/14/23 indicated that Resident 4 was an elopement risk due to dementia and wandering behavior, and interventions included the use of a Wander Guard on the right wrist. However, documentation from 3/1/24 through 3/5/24 showed that the device was not verified for placement four times out of 15 opportunities, and there was no documentation of device placement verification from 3/13/24 through 3/22/24. Additionally, the order to test the Wander Guard weekly was discontinued on 3/11/24, and a 3/20/24 Nursing Note indicated that Resident 4 no longer attempted to elope and requested orders to discontinue the Wander Guard. Despite this, the Wander Guard was still in place on 3/18/24 and 3/22/24, and it triggered an alarm when a staff member attempted to take Resident 4 out of the facility for an appointment on 3/22/24. Interviews and observations revealed inconsistencies in the assessment and monitoring of the Wander Guard. On 3/21/24, an LPN Unit Manager stated that Resident 4 was not a wander risk, yet the Wander Guard was still in place the following day. The lack of consistent documentation and assessment placed Resident 4 at risk for potential abuse or neglect, as the continued use of the physical restraint was not adequately justified or monitored. This deficiency highlights the facility's failure to ensure that each resident is free from the use of physical restraints unless needed for medical treatment.
Failure to Conduct Timely Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to conduct a Significant Change Minimum Data Set (MDS) assessment within the required timeframe for a resident who was reviewed for hospice care. The resident, who was admitted to the facility in 2024 with a diagnosis of heart disease, was approved and certified for hospice services by a physician on February 3, 2024. However, a review of the resident's clinical record revealed that a significant change MDS was not completed within 14 days after the resident was admitted to hospice. On March 20, 2024, the MDS Coordinator acknowledged that the significant change MDS was not conducted after the resident was admitted to hospice.
Failure to Revise Care Plans for Dialysis, Hospice, and Pain Management
Penalty
Summary
The facility failed to ensure care plans were revised for three residents reviewed for dialysis, hospice, and pain management. Resident 13, who was admitted with kidney failure, had a change in dialysis start times that was not updated in the care plan. Despite the resident's dialysis times changing to an earlier schedule, the care plan still reflected the old times, and staff acknowledged the care plan was not updated accordingly. Resident 22, admitted with heart disease and later certified for hospice services, had a care plan that did not reflect the hospice admission, including the name of the hospice agency, the resident's advance directive status, and the plan for the resident to remain at the facility. Staff failed to communicate these changes, resulting in an outdated care plan that did not align with the resident's current needs and services provided by hospice. Resident 47, admitted with diabetes, experienced increased pain due to hemorrhoids, which was documented in progress notes but not updated in the care plan. Despite multiple reports of pain and new orders for treatment, the care plan did not reflect the resident's ongoing pain management needs. Staff acknowledged the oversight, indicating a lack of communication and follow-through in updating the care plan to address the resident's pain effectively.
Failure to Provide Elbow Braces for Resident with Contractures
Penalty
Summary
The facility failed to provide splints to reduce contractures for a resident with diagnoses including contractures of the left and right elbows. The resident's care plan indicated the need for elbow braces during the day for six hours, but a quarterly MDS revealed no splint or brace was provided during a seven-day review period. The Kardex for CNAs had no reference to the resident's elbow braces. Observations and interviews revealed that the resident's elbow braces were offered inconsistently, and staff were unaware of the need for the braces. The resident reported that the braces were last applied three days prior and that staff did not know how to correctly apply them. The LPN-Unit Manager acknowledged the inconsistency and the need for the braces to be included in the Kardex for CNAs.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, leading to an increased risk of infections. The resident, who was admitted with diagnoses including quadriplegia and bladder dysfunction, had a history of UTIs related to a chronic indwelling catheter. Despite a care plan revision and a urology clinic note indicating the need for a follow-up appointment and catheter change, the facility did not schedule the necessary follow-up appointment. Additionally, when the resident was eventually scheduled for a catheter change, the facility lacked the appropriate supplies to perform the procedure, further delaying the necessary care. On multiple occasions, staff acknowledged the oversight in scheduling the follow-up urology appointment and the lack of appropriate supplies to change the suprapubic catheter. The resident was observed at the nurses' station awaiting a urology appointment, which was later canceled because the facility was informed that the catheter change could be done on-site. However, the facility was unable to perform the procedure due to the unavailability of the correct catheter size, and management was aware of the situation but still waiting for the supplies to be delivered.
Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to maintain healthy nutritional parameters for Resident 4, who was diagnosed with dysphagia and required specific dietary interventions. The care plan for Resident 4 included supervision and assistance during meals, the use of a teaspoon for eating, and the avoidance of straws. However, observations revealed that Resident 4 was left unsupervised for 20 minutes while eating breakfast, and there was inconsistency in the care plan regarding the use of straws. Additionally, the resident's nutritional supplements were discontinued without proper documentation of refusals, and there was a lack of clarity in physician orders after the resident's readmission. Staff interviews indicated that the care plan was not updated, and staff relied on verbal reports rather than checking the care plan. The MDS Coordinator admitted to missing the inconsistency in the care plan, and the LPN Unit Manager confirmed that the physician orders were unclear and needed clarification. The Registered Dietitian stated that nutritional supplements were not ordered unless the resident enjoyed them, despite the resident's significant weight loss and nutritional risk factors. This lack of adherence to the care plan and proper documentation placed Resident 4 at risk for further weight loss and compromised nutritional status.
Failure to Implement Pain Management Interventions
Penalty
Summary
The facility failed to ensure pain interventions were implemented to manage a resident's pain effectively. Resident 47, who was admitted in 2023 with a diagnosis of diabetes, reported increased pain due to hemorrhoids starting in December 2023. Despite multiple reports of pain and a new order for hemorrhoid treatment, the resident's care plan was not updated to include pain management for hemorrhoids. Additionally, the facility did not provide the prescribed witch hazel pads or a specialized cushion in a timely manner, leading to the resident experiencing ongoing pain and decreased activity levels. Staff interviews revealed that the MDS Coordinator was not informed of the resident's pain, preventing updates to the care plan. The LPN Unit Manager and other staff members acknowledged the lack of communication and the unavailability of the appropriate witch hazel pads, which caused further discomfort to the resident. The Director of Therapy Services was also unaware of the order for a specialized cushion until much later, delaying its provision. These lapses in communication and failure to implement prescribed interventions resulted in the resident's continued pain and inability to participate in daily activities.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations for a resident reviewed for medications. The resident, admitted in 2023 with diagnoses including arthritis and anxiety, had a pharmacy review on 12/25/23 that recommended labs be obtained to evaluate several medications. However, there was no evidence in the clinical record that the labs were obtained. This was confirmed by the Staff Development Coordinator on 3/21/24, indicating that the labs were not obtained timely.
Failure to Obtain Routine Labs for Medication Monitoring
Penalty
Summary
The facility failed to obtain routine labs to monitor the effectiveness of medications for one resident. A pharmacy review on 12/25/23 identified the need for routine labs to evaluate the resident's medications for high cholesterol, diabetes, vitamin D, B12 deficiencies, sodium, and potassium levels. Another pharmacy review on 2/27/24 noted that the labs were ordered by the physician on 2/19/24, and the facility was requested to obtain a copy of the results for the resident's clinical record. However, there was no evidence in the resident's clinical record that the labs were obtained until 3/1/24. This was confirmed by the Staff Development Coordinator on 3/21/24.
Failure to Reschedule Colonoscopy
Penalty
Summary
The facility failed to ensure a resident's colonoscopy was rescheduled after the initial appointment was canceled. Resident 35, admitted in 2021 with a diagnosis of a stroke, experienced abnormal weight loss and had a colonoscopy scheduled to investigate the cause. The colonoscopy was set for 2/15/24, but the resident refused to consume all the preparation medication on 2/14/24, leading to the test's cancellation. The physician was notified, but this was not documented in the resident's clinical record, and there was no follow-up to reschedule the colonoscopy. As of 3/20/24, the colonoscopy had not been rescheduled, placing the resident at risk for delayed treatment.
Failure to Obtain Dental Services for Resident
Penalty
Summary
The facility failed to obtain dental services for a resident diagnosed with malnutrition and quadriplegia. The resident had her/his teeth extracted in May 2023 and required dentures. Despite a care plan revision in March 2024 to coordinate dental care and transportation, the resident continued to request dentures without any update. The social worker attempted to arrange a denture appointment but was waiting for the Director of Nursing Services to discuss the risks and benefits of the procedure with the resident. The Director of Nursing Services acknowledged that follow-up on the resident's request was lacking since February 2024.
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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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