Village Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Gresham, Oregon.
- Location
- 3955 Se 182nd Avenue, Gresham, Oregon 97030
- CMS Provider Number
- 385068
- Inspections on file
- 19
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Village Health Care during CMS and state inspections, most recent first.
A resident with spinal stenosis and chronic kidney disease, who required partial to moderate assistance with bathing and transfers, was being transported back to their room in a rolling shower chair by a NA student. At the doorway, the chair became stuck on a transition strip; despite the resident stating they were usually taken into the room backwards because of this strip, the NA student attempted to free the chair by lifting on the backrest. The backrest detached, causing the resident to fall backwards to the floor. The resident reported fear and some back pain after the fall, and staff assessment found no major injury. The DNS later confirmed the fall was due to incorrect and unsafe techniques used by the NA student.
A resident with significant mobility and skin integrity risks developed multiple new pressure ulcers over several months. Despite existing care plan interventions, staff did not document reassessment or implement additional interventions after new wounds appeared. Nursing staff acknowledged that further measures should have been taken, but these were not documented or followed up.
A resident with heart failure and COPD did not receive prescribed lasix for four days due to a charting error and system glitch after a medication order change. The lapse led to worsening symptoms, including swelling and respiratory distress, resulting in hospitalization for acute hypoxemic respiratory failure. The facility confirmed the medication error and its clinical consequences.
The facility failed to follow proper infection control practices during CBG monitoring for a resident with diabetes and renal disease, as staff did not use barriers or perform hand hygiene between glove changes. Additionally, Enhanced Barrier Precautions were not implemented for residents with MDROs, and droplet precautions were not followed for a resident with influenza, as staff were unaware of the necessary precautions and PPE was not readily available.
The facility did not ensure residents were informed of their rights both orally and in writing on an ongoing basis. Resident Council members were unaware of their rights and unsure if they were posted or accessible. Meeting minutes from several dates showed no evidence of rights being reviewed. The administrator acknowledged the issue, believing rights were reviewed through the Resident Council.
The facility did not have a system to deliver mail to residents on Saturdays. During a Resident Council interview, residents reported not receiving mail on Saturdays. A review of activity participation charts from November 2024 to January 2025 confirmed this issue, and the administrator acknowledged the lack of a Saturday mail delivery system.
The facility failed to comprehensively assess three residents for medications, ROM, and behaviors, resulting in unassessed needs and a lack of person-centered care plans. One resident with major depression and schizophrenia lacked detailed analysis in their CAAs for psychotropics and other areas. Another resident with a stroke and hemiplegia had incomplete analysis in their Functional Abilities CAA. A third resident showed a decline in mood, but their health record lacked assessment of contributing factors, and no CAA was completed.
The facility failed to provide person-centered activity programs for four residents, leading to a risk of decline in psychosocial well-being. Residents with various diagnoses, including stroke, schizophrenia, dementia, and congestive heart failure, were not engaged in activities despite having interests in music, reading, and social interactions. Staff confirmed the lack of activity care plans and awareness of residents' preferences, resulting in residents being left alone and unengaged.
The facility failed to provide a designated licensed nurse (LN) as a charge nurse for 36 out of 81 shifts over a period of nearly a month. This lack of LN coverage was confirmed by the Staffing Coordinator and the Administrator, who was unaware of the staffing situation. The absence of LN coverage placed residents at risk for unmet needs, as the facility did not ensure the necessary nursing services for resident safety and well-being.
The facility did not ensure RN coverage for at least eight consecutive hours per day on nine occasions, as required. This lack of coverage was acknowledged by the Staffing Coordinator and Administrator, placing residents at risk for inadequate RN assessments and care.
A resident with upper extremity impairments experienced difficulty feeding themselves due to the use of plastic and Styrofoam dishware, which was not sturdy enough, leading to spills. This practice, ongoing for at least two months, was due to regular dishware being unavailable. Staff interviews confirmed the issue, and the new Dietary Manager acknowledged the non-dignified nature of the dishware after a facility walk-through.
A facility failed to inform a resident with generalized anxiety disorder about the risks and benefits of psychotropic medications and did not obtain consent for their use. The resident was receiving Citralopram Hydrobromide and Aprazolam as prescribed, but there was no documentation of informed consent. The DNS confirmed that nursing staff were expected to review medication risks and benefits with residents, which was not done in this instance.
A resident, admitted with a heart attack and fractured leg, was not involved in their care planning despite being cognitively independent and their own responsible party. The resident was unaware of their care plan contents, and staff confirmed the absence of documentation or a care conference. The DNS expected care conferences to occur within 72 hours of admission.
The facility failed to assess the appropriateness of self-administration of medication for two residents, placing them at risk for unsafe medication administration. One resident with a stroke had a nasal spray within reach without an assessment, and another with COPD had an albuterol inhaler without being assessed for self-administration safety. Staff confirmed that neither resident had been evaluated for their ability to self-administer these medications.
A resident with Aphasia had their call light out of reach, contrary to their care plan. Observations showed the call light wrapped around the bed frame, and residents reported similar issues during a council meeting. A CNA and the DNS confirmed the call light was inaccessible, highlighting a failure to follow the care plan.
The facility failed to provide a SNF ABN to a resident who was admitted with Medicare A benefits. The resident's Medicare Part A benefits ended, and they were financially responsible for their care without being informed of the daily out-of-pocket costs. The DNS reported that the facility was not providing SNF ABN notifications to residents or their representatives.
The facility failed to ensure accurate assessments for two residents, leading to potential unmet care needs. A resident with diabetes had inconsistent MDS assessments regarding cognitive status and opioid medication use. Another resident with anxiety disorder had discrepancies in MDS assessments about the use of corrective lenses, despite being observed wearing glasses. Staff confirmed the inaccuracies.
A facility failed to conduct a new and accurate Level I PASARR for a resident with Bi-Polar Disorder, Major Depressive Disorder, and anxiety, who exhibited behaviors such as hallucinations and self-isolation. Despite these indicators, no corrected Level I PASARR or referral for Level II PASARR was made, as acknowledged by staff. This oversight risked delaying care and services for the resident's mental health needs.
The facility failed to create comprehensive baseline care plans within 48 hours for two residents upon admission, leading to unmet care needs. One resident with complex medical conditions had a care plan addressing only nutrition, while another resident with cognitive impairment had no care plan, resulting in a fall and hip fracture. Staff acknowledged these oversights, indicating a lapse in immediate care planning.
A resident with anxiety disorder experienced impaired vision due to a scratched lens on their glasses, which were damaged during a fall at the facility. Despite the resident's report of hazy vision, the facility did not provide the necessary assistance to repair or replace the glasses, as confirmed by staff.
The facility failed to provide regular restorative nursing services for two residents with impaired mobility due to staffing issues. One resident, with hemiparesis, reported increased difficulty in walking and pain due to irregular services. Another resident expressed a desire to be more active, but staffing shortages led to inconsistent service delivery. Staff confirmed the lack of a tracking system for restorative services.
A resident with anxiety, cancer, and an abscess of the lower limb did not receive timely pain medication due to the facility's failure to update pain medication instructions. The resident's Comprehensive Care Plan did not address specific pain needs, leading to inconsistent interpretation of PRN orders by nursing staff. Despite the provider's clarification on dosing intervals, the resident's MAR and Care Plan were not updated, resulting in the resident not receiving timely oxycodone doses.
A facility failed to ensure proper dialysis services and communication for a resident with end-stage renal disease. The required communication reports were not completed, and necessary assessments were not conducted upon the resident's return from dialysis, placing the resident at risk for complications.
A facility failed to act on pharmacy recommendations to limit the use of PRN antipsychotic medication for a resident with major depression, schizophrenia, and anxiety disorder. The resident's MARs indicated continuous use of Seroquel beyond the recommended 14-day limit. The Consultant Pharmacist had sent reviews and notes to the prescriber, but there was no evidence that the December pharmacy review was completed or acted upon.
A facility failed to limit the PRN use of Seroquel, an antipsychotic medication, to 14 days for a resident with major depression, schizophrenia, and anxiety disorder. The medication was administered 15 times in December and eight times in January before the order was adjusted to a 14-day duration. This was confirmed by a Corporate Nurse Consultant, highlighting a lapse in adhering to the 14-day limitation for PRN antipsychotic use.
The facility inaccurately documented physician orders for two residents, leading to discrepancies in care. One resident received the wrong diet texture, while another received conflicting weight-bearing instructions. Staff confirmed the errors in transcription and documentation.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not address the use of PRN diazepam for auras or seizure activity, nor potential cognitive changes. Another resident's care plan lacked specific interventions for behaviors related to mental illness. Staff acknowledged the absence of resident-centered interventions.
A facility failed to provide proper care for a resident with skin conditions and did not ensure person-centered medication management for another resident. One resident had significant bruising and an abrasion without documented assessments or treatments. Another resident experienced issues with medication management, expressing frustration over the administration of sedating medications, which was not adequately addressed in their care plan.
The facility failed to post accurate staffing information, with 17 days of incomplete or inaccurate Direct Care Staff Daily Reports. Issues included missing daily census data, absent signatures, and incorrect staff numbers. The Administrator acknowledged these inaccuracies.
Fall from Rolling Shower Chair Due to Improper Handling at Doorway Transition
Penalty
Summary
The facility failed to ensure safe use of bathing equipment and adequate supervision during transport in a rolling shower chair, resulting in a fall for one resident. The resident, admitted with diagnoses including spinal stenosis and chronic kidney disease, had a care plan indicating a need for partial to moderate assistance with bathing and bathing transfers. On the date of the incident, a NA student assisted the resident back to their room in a rolling shower chair. As they attempted to cross the transition strip at the doorway, the shower chair became stuck. The resident informed the NA student that they were usually assisted into the room backwards because of the transition strip. The NA student attempted to dislodge the stuck wheel by lifting up on the backrest of the rolling shower chair, causing the backrest to detach and the resident to fall backwards onto the floor. The resident recalled falling out of the shower chair and reported feeling afraid immediately after the incident. Staff, including an RN and the shower aide, assessed the resident after the fall and noted no major injury, with the resident able to stand and walk to bed, though minimal increase in back pain was reported. The DNS confirmed that the fall occurred due to incorrect and unsafe techniques used by the NA student when handling the rolling shower chair at the doorway transition strip.
Failure to Re-Evaluate and Update Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to re-evaluate and update preventative interventions for a resident who developed multiple new pressure ulcers. The resident, who had a history of stroke with left-sided deficits, impaired mobility, incontinence, and other comorbidities, was identified as being at risk for skin integrity issues. Despite the care plan outlining several interventions such as frequent repositioning, offloading, and moisture management, the resident developed a superficial open area on the left buttock, moisture-associated skin damage to the coccyx, and an unstageable pressure wound to the heel over a period of several months. Record review and staff interviews revealed that there was no documented evidence of reassessment or modification of the care plan interventions after the development of new pressure ulcers. Nursing staff acknowledged that additional interventions should have been implemented but were not. Recommendations for interventions, such as a pressure-reducing air mattress, were made verbally but not documented or followed up. The lack of timely re-evaluation and implementation of new interventions contributed to the resident developing additional pressure ulcers.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A resident with chronic obstructive pulmonary disease and congestive heart failure was admitted to the facility and had physician orders for lasix to manage fluid buildup. The resident's lasix regimen was changed from once daily to twice daily for five days due to increased swelling, requiring the original order to be stopped. Due to a charting error on the medication administration record (MAR) and a reported glitch in the computer system, the resident did not receive lasix for four consecutive days. The nurse responsible for the medication change was unable to place the medication on hold in the system, discontinued the original order, and communicated her concerns to the provider and care manager, but assumed the issue would be addressed by others during clinical rounds. As a result of not receiving lasix, the resident developed significant clinical symptoms, including increased swelling, shortness of breath, and lowered oxygen levels. The resident was subsequently hospitalized for acute hypoxemic respiratory failure, with hospital records indicating volume overload and elevated BNP levels attributed to medication non-adherence. The facility confirmed the medication error and its impact through internal investigation and communication with the State Survey Agency.
Infection Control Deficiencies in Hand Hygiene and Precautionary Measures
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during capillary blood glucose (CBG) monitoring for a resident with diabetes and end-stage renal disease. Staff 11, a registered nurse, did not use a barrier on the resident's dirty bedside table when placing CBG supplies, nor did they perform hand hygiene between glove changes. The glucometer was placed on the medication cart without a barrier, and the cart was not disinfected. These actions were contrary to the facility's infection control policies and placed the resident at risk of contamination. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Observations revealed that there was no signage or personal protective equipment (PPE) supplies outside the rooms of residents requiring EBPs. Staff members were unaware of the need for gown and glove use during high-contact care activities, and the facility did not have the necessary PPE kits available, which was acknowledged by the Director of Nursing Services and the Regional President. Additionally, the facility did not follow droplet precautions for a resident diagnosed with influenza. Although a PPE cart was present outside the resident's room, there was no sign indicating the type of precautions to be followed. Staff members were unsure of the required precautions, and housekeeping staff did not wear appropriate eye protection while in the resident's room. The Director of Nursing Services confirmed that droplet precautions should have been in place until the resident was reassessed and physician orders updated.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. This deficiency was identified during an interview with Resident Council members on January 30, 2025, who stated they were not informed of resident rights regularly and were unsure if any rights were posted in the facility or where to obtain them. A review of Resident Council Meeting minutes from November 12, 2024, December 10, 2024, and January 17, 2025, showed no evidence that resident rights were provided to or reviewed with residents during these meetings or by any other method. The facility's administrator, Staff 1, acknowledged the issue, stating he believed resident rights were reviewed through the Resident Council and was unaware of any other method used to communicate these rights.
Lack of Saturday Mail Delivery System
Penalty
Summary
The facility failed to have a system in place to deliver mail to residents on Saturdays, as determined through interviews and record reviews. During a Resident Council group interview, residents reported that their mail was not delivered on Saturdays. A review of resident activity participation charts from November 2024 through January 2025 showed no evidence of mail delivery on Saturdays. The facility's administrator confirmed the absence of a system for Saturday mail delivery.
Deficiencies in Comprehensive Resident Assessments
Penalty
Summary
The facility failed to comprehensively assess three residents for medications, range of motion (ROM), and behaviors, leading to unassessed needs and a lack of person-centered care plans. Resident 15, admitted in 2019 with diagnoses including major depression and schizophrenia, had an annual MDS assessment indicating mild cognitive impairment and was prescribed psychotropic medications. However, the Care Area Assessments (CAAs) for psychotropics, falls, nutrition, and functional ability lacked a detailed analysis of the resident's conditions, behaviors, and risk factors associated with the use of psychotropic medications. Staff confirmed that the CAAs did not include an analysis of the triggered concerns. Resident 33, admitted in 2021 with a stroke and hemiplegia, was identified as cognitively intact but had a ROM impairment and used mobility aids. The Functional Abilities CAA did not analyze the resident's current level of function, goals, or participation in the restorative program, nor did it identify potential negative outcomes. Resident 18, admitted in 2023 with major depression, showed a decline in mood and affect, but the health record lacked an assessment of the cause or contributing factors. The MDS did not include a comprehensive assessment of the resident's mood and behaviors, and no CAA was completed. Staff confirmed the deficiencies in the assessments and documentation for these residents.
Failure to Provide Person-Centered Activity Programs
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for four sampled dependent residents, leading to a risk of decline in psychosocial well-being and diminished quality of life. Resident 57, admitted with diagnoses including stroke, schizophrenia, and dementia, had no evidence of an Activities care plan completed. Despite having interests in music, reading, and religious activities, Resident 57 was observed mostly alone in her/his room or in the hallway, with no engagement in group or one-on-one activities. Staff confirmed the lack of an activity care plan and awareness of Resident 57's preferences. Resident 17, with a history of stroke and aphasia, also experienced severely impaired cognition. Although the care plan directed staff to assist and encourage participation in activities, no resident-centered interventions were found in the health record. Observations revealed Resident 17 often remained in bed with no engagement in activities, and staff confirmed the lack of in-room activities and awareness of the resident's enjoyment of television and music. Resident 24, cognitively intact and interested in various activities, had a care plan that lacked resident-centered interventions. Observations showed the resident was not engaged in group activities or provided with one-on-one activities. Staff confirmed the absence of activities and the failure to get the resident out of bed for group activities. Additionally, Resident 269, admitted with congestive heart failure, had no assessment of activity preferences completed and was not invited to participate in activities, despite expressing interest. Staff acknowledged the oversight in completing the activity assessment within the required timeframe.
Failure to Provide Licensed Nurse Coverage
Penalty
Summary
The facility failed to ensure that a designated licensed nurse (LN) served as a charge nurse for 36 out of 81 shifts between January 1, 2025, and January 27, 2025. This deficiency was identified through a review of the facility's Direct Care Staff Daily Reports, which showed that multiple shifts across various days lacked LN coverage. Specifically, the absence of LN coverage was noted on several day, evening, and night shifts throughout the month. The Staffing Coordinator confirmed the lack of LN coverage on the specified dates and shifts, and the Administrator was unaware of whether an LN was staffed during these times. This failure placed residents at risk for unmet needs, as the facility did not provide the necessary nursing and related services to ensure resident safety and well-being.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days a week, for 9 out of 27 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage for the required hours on specific dates. The Direct Care Staff Daily Reports from January 3 to January 27, 2025, indicated the absence of RN coverage on nine separate days. Staff 17, the Staffing Coordinator, and Staff 1, the Administrator, both acknowledged the lack of RN coverage on the identified days, but no additional information was provided. This failure placed residents at risk for lack of timely RN assessments and care.
Inappropriate Dishware Use Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by the use of inappropriate dishware for meals. A resident, admitted in 2014 with diagnoses including adult failure to thrive and anxiety, was observed receiving meals in plastic medication glasses and Styrofoam dishware over several days. The resident, who had impairments in both upper extremities, reported difficulty feeding themselves due to the lack of sturdiness of the dishware, resulting in spilled food and drinks. This practice had been ongoing for at least two months, according to the resident. Staff interviews revealed that the use of plastic and Styrofoam dishware was due to regular glassware being lost or unavailable. A CNA confirmed the use of such dishware for multiple residents, while the new Dietary Manager was unaware of the situation until it was brought to his attention. Upon conducting a walk-through, the Dietary Manager confirmed the widespread use of non-dignified dishware, acknowledging it was not appropriate or home-like for the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent for their use. This deficiency was identified for one of five sampled residents, who was admitted with a diagnosis of generalized anxiety disorder. The resident's Medication Administration Record (MAR) indicated they were receiving Citralopram Hydrobromide and Aprazolam as prescribed by their physician. However, there was no documentation in the resident's health record to show that the resident or their representative was informed about the risks and benefits of these medications, nor was there evidence of consent being obtained. The Director of Nursing Services (DNS) confirmed that it was expected for nursing staff to review the risks and benefits with residents before administering the medications, which did not occur in this case.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of their person-centered care plan. The resident, who was admitted with diagnoses of myocardial infarction and a fractured leg, was cognitively independent and their own responsible party. Despite this, there was no evidence in the clinical record that the resident was involved in the care planning process. The resident confirmed that facility staff did not consult them about their care plan, and they were unaware of its contents. Staff members, including an RNCM and the DNS, acknowledged the lack of documentation and involvement of the resident in the care planning process, which was expected to occur within 72 hours of admission.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess the appropriateness of self-administration of medication for two residents, which placed them at risk for unsafe medication administration. Resident 18, who was admitted in 2023 with a diagnosis of stroke, was observed with a bottle of Fluticasone Propionate Nasal spray within reach on their overbed table. A review of the resident's health record revealed that no self-administration assessment had been completed to determine the resident's ability to safely self-administer the nasal spray. Staff confirmed that the resident had not been assessed for self-medication and that the medication should not have been left in the room. Similarly, Resident 60, admitted in December 2024 with chronic obstructive pulmonary disease (COPD), was found with an albuterol sulfate inhaler on their bedside table. The resident stated that the inhaler was albuterol sulfate, yet no assessment for self-administration of medications had been performed. Staff confirmed that Resident 60 had not been assessed for safety with self-administration of the inhaler, and it should not have been left with the resident before determining their ability to self-administer the medication safely.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident diagnosed with Aphasia, which affects communication abilities. The resident's care plan, dated 1/29/25, directed staff to keep the call light accessible. However, observations on 1/29/25 at 9:31 AM and 10:47 AM revealed that the call light was wrapped around the base of the bed's head frame, making it unreachable. During a Resident Council meeting on 1/30/25, residents reported that their call lights were often tied to the back of their beds, preventing them from calling for assistance. Staff 8, a CNA, confirmed on 1/30/25 that the call light was not within reach. On 2/3/25, Staff 2, the DNS, also confirmed the call light's inaccessibility and stated that the care plan should have been followed.
Failure to Provide SNF ABN Notification
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident, identified as Resident 34, who was admitted with Medicare A benefits. The Notice of Medicare Non-Coverage (NOMNC) indicated that the resident's Medicare Part A benefits ended on October 14, 2024. However, the resident remained in the facility and was financially responsible for their care from October 15, 2024, until December 1, 2024. There was no documentation showing that the SNF ABN notification was provided to the resident or their representative to inform them of the daily out-of-pocket costs. On January 29, 2025, Staff 2, the Director of Nursing Services (DNS), reported that the facility was not providing SNF ABN notifications to residents or their representatives, despite the expectation that they should be informed of such costs.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential unmet care needs. Resident 25, admitted in 2018 with diabetes, was observed to be alert and oriented, yet their 12/21/24 Quarterly MDS inaccurately indicated they were rarely/never understood and omitted a diagnosis for opioid medication use. This was inconsistent with their 3/20/24 Annual MDS, which showed a BIMS score of 15 and a chronic pain diagnosis. Staff 2 acknowledged the inaccuracy. Similarly, Resident 45, admitted in 4/2024 with anxiety disorder, had discrepancies in their MDS assessments regarding the use of corrective lenses. The 8/28/24 MDS noted the use of glasses, while the 12/1/24 MDS did not, despite the resident being observed wearing glasses and confirming long-term use. Staff 2 confirmed the inaccuracy in the most recent assessment.
Failure to Conduct Accurate PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to conduct a new and accurate Level I PASARR (Pre-Admission Screening and Resident Review) for a resident who was admitted with diagnoses including Bi-Polar Disorder, Major Depressive Disorder, and anxiety. The initial PASARR I, completed by the hospital upon admission, indicated no serious mental illness. However, the resident's care plan included interventions for safety and behavioral concerns, such as administering antidepressant, antipsychotic, and mood stabilizer medications, and reporting agitation, aggression, or depression to nursing staff. The resident also experienced hallucinations, which were documented in a social services summary. Despite these indicators, there was no evidence in the resident's health record of a corrected Level I PASARR or a referral for a Level II PASARR for behavioral services. Observations over several days noted the resident self-isolating in their room. Staff members, including the Activity Director/Social Service Director and the DNS, acknowledged the resident's behaviors and expressed an expectation that a Level II PASARR should have been completed. This oversight placed the resident at risk for delayed care and lack of necessary services to support their mental health needs.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered baseline care plan within 48 hours of admission for two residents, leading to unmet care needs. Resident 220, admitted with multiple complex medical conditions including acute and chronic respiratory failure, dysphagia, and high fall risk, had a baseline care plan that only addressed nutritional concerns. This omission left significant care needs such as oxygen therapy, BIPAP use, and wound care unaddressed. Staff confirmed that the baseline care plan did not reflect the resident's active problems, indicating a lack of guidance for staff on the resident's care requirements. Similarly, Resident 41, admitted with severe cognitive impairment and orthostatic hypotension, did not have a baseline care plan developed during their initial stay. This oversight occurred despite the resident's need for assistance with transfers and the absence of a history of elopement. The lack of a care plan was acknowledged by staff after the resident experienced a fall resulting in a hip fracture, which required hospitalization. The absence of a baseline care plan for both residents highlights a failure in the facility's process to ensure immediate and comprehensive care planning upon admission.
Failure to Assist Resident with Glasses Repair
Penalty
Summary
The facility failed to provide necessary assistance for the repair of a resident's glasses, which were damaged as a result of a fall within the facility. The resident, who was admitted in April 2024 with a diagnosis of anxiety disorder, was observed wearing glasses with a significant scratch on the right lens, impairing their vision. This issue was noted during an observation in January 2025, where the resident reported that the scratch had been present for a long time, causing hazy vision. Staff confirmed that the damage occurred due to a fall at the facility, and acknowledged that the glasses should have been repaired or replaced.
Failure to Provide Regular Restorative Nursing Services
Penalty
Summary
The facility failed to provide regular restorative nursing services to maintain or improve the range of motion (ROM) and mobility for two residents. Resident 33, admitted with a stroke and hemiparesis, was cognitively intact and expressed a desire to be active. Despite having a care plan that included restorative nursing services three to five times a week, the resident reported not receiving these services regularly due to the restorative aide being reassigned to work as a CNA. This lack of regular services led to increased difficulty in walking and pain during dressing. Staff confirmed the reassignment of the restorative aide and acknowledged the absence of a system to track restorative services. Similarly, Resident 18, also admitted with a stroke, had a care plan for impaired mobility that included passive ROM exercises and a power wheelchair program. However, the resident expressed a desire to be more active and out of bed, indicating a lack of regular restorative services. Staff confirmed that due to staffing issues, restorative services were often unavailable, and there was no system in place to track the services provided or resident participation. The DNS admitted to the absence of a consistent restorative program and expected Resident 18 to receive services as planned.
Failure to Update Pain Medication Instructions for Resident
Penalty
Summary
The facility failed to update pain medication instructions to include resident-centered dosing for a resident with anxiety, cancer, and an abscess of the lower limb. The resident, who had mild cognitive impairment and experienced daily pain, was prescribed oxycodone HCl 5 MG to be taken three times a day as needed. However, the Comprehensive Care Plan did not address the resident's specific pain related to the lower extremity infection or the need for pain control during dressing changes. This oversight led to inconsistent interpretation of PRN orders by nursing staff, resulting in the resident not receiving timely pain medication. The resident reported not always receiving oxycodone timely, as nursing staff interpreted the TID dosing as three times a day or every 8 hours, despite the provider's note indicating a minimum time between doses could be three hours. On one occasion, the resident did not receive a bedtime dose of oxycodone and was given Tylenol instead, which did not relieve the pain. The Medication Administration Record (MAR) showed a gap in dosing, with the resident not receiving another dose until the following morning. Despite the provider's clarification in the progress notes, the resident's MAR and Care Plan were not updated to address the timing of the pain medication.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis services and communication with the dialysis provider for a resident with end-stage renal disease. The facility's policy required communication with the dialysis center through a transfer form and the exchange of lab results, weights, and other pertinent information. However, for the resident in question, there was only one partially completed communication report, and no evidence that the facility received or sought the necessary information from the dialysis center for any of the resident's nine dialysis treatments. The resident, who was admitted with diagnoses including diabetes and end-stage renal disease, reported that upon returning from dialysis, nursing staff did not perform an assessment or check the dialysis port. Staff interviews confirmed that the required communication reports were not completed, and the necessary assessments were not conducted upon the resident's return from dialysis. This lack of communication and assessment placed the resident at risk for dialysis complications and delayed treatment.
Failure to Act on Pharmacy Recommendations for PRN Antipsychotic Use
Penalty
Summary
The facility failed to respond to pharmacy recommendations regarding the use of PRN antipsychotic medication for a resident. The resident, admitted in May 2019, had diagnoses of major depression, schizophrenia, and anxiety disorder. The December 2024 and January 2025 Medication Administration Records (MARs) showed an order for Seroquel, an antipsychotic, to be administered every six hours as needed for agitation and anxiety, with a start date of December 2, 2024, and an end date of January 28, 2025, when the order was changed to a 14-day duration. However, there was no evidence that the December pharmacy review was completed or acted upon. The Consultant Pharmacist stated that reviews and notes were sent to the prescriber on December 20, 2024, and January 27, 2025, regarding the need for a 14-day limit and to ensure evidence of in-person physician visits.
Failure to Limit PRN Antipsychotic Use to 14 Days
Penalty
Summary
The facility failed to ensure that the PRN use of an antipsychotic medication, Seroquel, was limited to 14 days for a resident diagnosed with major depression, schizophrenia, and anxiety disorder. The resident was admitted in 2019 and had an order for Seroquel 25 mg every six hours PRN for agitation/anxiety, in addition to scheduled doses. The medication order started on December 2, 2024, and was not adjusted to a 14-day duration until January 28, 2025. During December 2024, the PRN dose was administered 15 times, and in January 2025, it was used eight times. This oversight was confirmed by Staff 13, a Corporate Nurse Consultant, on January 30, 2025, indicating a failure to adhere to the 14-day limitation for PRN antipsychotic use.
Inaccurate Documentation of Physician Orders for Two Residents
Penalty
Summary
The facility failed to accurately document physician orders for two residents, leading to discrepancies in their care. Resident 220, who was admitted with conditions including dysphagia and malnutrition, was supposed to receive a mechanical soft diet as per the hospital discharge orders. However, the facility's records incorrectly documented the diet as minced and moist textures, resulting in the resident receiving pureed foods, which they did not prefer and refused to eat. This error was acknowledged by the staff, who confirmed that the transcription of the diet orders was incorrect. Similarly, Resident 269, admitted with a diagnosis of atherosclerosis, was instructed to be weight-bearing as tolerated on their left lower extremity according to hospital discharge instructions. However, the facility's nursing evaluation and care plan inaccurately documented the resident as non-weight-bearing. This inconsistency led to confusion, as the resident received conflicting instructions from nurses and therapists. The Director of Nursing Services confirmed the error in the documentation of weight-bearing precautions.
Deficiencies in Resident Care Plans for Medication Management and Behavioral Interventions
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific needs. Resident 118, admitted with diagnoses including epilepsy, anxiety disorder, and depression, had an incomplete care plan that did not address the use of PRN diazepam for auras or seizure activity, nor did it consider potential cognitive changes or behavioral needs identified in care conference notes. Despite the resident expressing concerns about their medication, the care plan lacked clarity on how the anxiety disorder manifested and did not provide a person-centered approach to medication management. Similarly, Resident 24, diagnosed with Bipolar Disorder, Major Depression, and anxiety, had a care plan that failed to address how their diagnoses and behaviors presented. The care plan did not provide specific interventions for staff to use when the resident exhibited behaviors such as visual hallucinations. Staff acknowledged the absence of resident-centered interventions in the care plan, which did not adequately address the resident's behavior related to mental illness.
Deficiencies in Skin Care and Medication Management
Penalty
Summary
The facility failed to provide care and treatment as care planned for a resident with skin conditions and did not ensure person-centered medication management for another resident. One resident, admitted in 2018 with diabetes, was observed with significant bruising and an abrasion on their lower right leg and arm. Despite these observations, there were no documented skin assessments, monitoring, or treatments for the bruising and abrasion, which was confirmed by the Director of Nursing Services (DNS). Another resident, admitted in August 2024 with a history of surgical repair of a fractured hip, epilepsy, depression, and anxiety disorder, experienced issues with medication management. The resident expressed frustration over medication administration, particularly regarding the concurrent use of sedating medications. Nursing staff hesitated to administer these medications simultaneously due to concerns about sedation, despite the resident's description of auras that could precede seizures. The resident's care plan was not updated to reflect specific administration instructions, leading to conflicts between the resident and nursing staff.
Inaccurate Staffing Information Posting
Penalty
Summary
The facility failed to post accurate and complete staffing information, as evidenced by a review of the Direct Care Staff Daily Reports from January 1 to January 27, 2025. During this period, 17 days were identified where portions of the staffing forms were left blank or contained inaccuracies, such as missing daily census data, absent signatures, and incorrect numbers of working staff. On January 27 and January 28, 2025, the Care Staff Daily Reports displayed incorrect information, including incomplete shifts and outdated data from the previous day. On January 30, 2025, the Administrator acknowledged that many of the reviewed reports were incomplete and inaccurately documented the number of staff working on several days.
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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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