Village Manor Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Wood Village, Oregon.
- Location
- 2060 Ne 238th Drive, Wood Village, Oregon 97060
- CMS Provider Number
- 38E174
- Inspections on file
- 21
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Village Manor Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was left unattended in the shower room without required supervision, a shower bench, or non-skid footwear. The resident was found by housekeeping staff after sustaining multiple pelvic fractures and internal bleeding, and staff confirmed that the care plan interventions to prevent falls were not followed.
A resident with a history of schizoaffective disorder struck another resident with psychosis in the face while the latter was sleeping. Staff responded to yelling, separated the residents, and called EMTs. The assaulted resident was not physically injured but reported feeling scared and uncomfortable sharing a room with the aggressor. Staff and documentation confirmed the incident met the definition of abuse.
A resident with schizophrenia and traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, but the LPN involved, being new, did not submit the required abuse report to the State Agency within the mandated timeframe, despite assistance from the DNS and another nurse.
A resident with borderline personality disorder was unable to independently operate their bedside light due to a shortened chain, leading to frustration and repeated requests for staff assistance. Staff had inconsistent knowledge about the resident's ability to use the light, and the care plan did not address the modification. The chain had been shortened for safety, but key staff were unaware this prevented the resident from using the light without help.
A resident with a history of anxiety, hallucinations, and disorientation was repeatedly administered haloperidol without documented indications or behaviors warranting its use. Multiple LPNs gave the antipsychotic for reasons such as agitation or difficulty sleeping, but failed to record specific symptoms, non-pharmacological interventions, or the effectiveness of the medication, resulting in the use of unnecessary psychotropic medication as a chemical restraint.
A resident with multiple psychiatric diagnoses was prescribed several psychotropic medications, but the facility did not include any interventions for the use of these medications in the resident's care plan. Review of the clinical record and confirmation by the DNS showed no resident-specific interventions were documented.
A resident with a history of stroke and swallowing difficulties experienced a choking episode during dinner that required the Heimlich maneuver by an LPN. Despite this event, the resident's diet was not immediately downgraded, and the speech-language pathologist was not notified until several days later. The delay in assessment and intervention following the choking incident led to the deficiency.
A resident with cognitive impairment and a care plan requiring smoking gloves to prevent burns was observed smoking without the gloves. The resident reported that staff did not offer the gloves, and staff confirmed the omission, resulting in a failure to follow the care plan for accident prevention.
Two residents with PTSD did not receive trauma-informed care as required by facility policy. Staff failed to complete trauma assessments or develop care plans addressing trauma triggers, and were unaware of the residents' trauma histories or specific needs. Both residents confirmed that trauma triggers and histories were not discussed with them.
A resident with anxiety, hallucinations, and disorientation was prescribed Olanzapine. The pharmacist recommended updating the medical record with specific symptoms, consideration of other causes, and use of nonpharmacological interventions if the antipsychotic was to continue. These recommendations were not followed, and the required documentation was missing from the clinical record.
Two residents received unnecessary medications when staff failed to follow physician orders to withhold midodrine for elevated SBP and senna for loose stools. Despite clear parameters, both medications were administered on multiple occasions when they should have been held, as confirmed by MAR reviews and staff interviews.
A resident with dementia and a history of frequent falls did not receive a physician-ordered PT evaluation after staff determined therapy was not appropriate due to recent prior therapy. The decision was not communicated to the provider, and the ordered service was not completed, leaving the resident without the specialized rehabilitative intervention intended to address fall risk.
Failure to Follow Fall Prevention Care Plan During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions designed to prevent falls for a resident with dementia who was identified as a fall risk. The resident's care plan specified the need for supervision and touch assistance during bathing, use of a shower bench or bathtub, and wearing non-skid footwear when up. Despite these interventions, the resident was found unattended in the shower room by housekeeping staff, not fully clothed, without socks or shoes, and without a shower bench present. The resident was in a shower stall rather than a bathtub, and staff interviews confirmed that the care plan was not followed. As a result of these failures, the resident sustained multiple complex pelvic fractures and internal bleeding, requiring transfer to the hospital for evaluation. Staff statements and administrative confirmation indicated that the resident was left alone in the shower room, and the required safety equipment and supervision were not provided at the time of the incident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
A resident with schizoaffective disorder was admitted to the facility and shared a room with another resident diagnosed with psychosis. On the night of the incident, staff heard yelling and discovered the first resident standing over the second resident's bed, having struck the resident in the face while the latter was sleeping. The assaulted resident reported being woken by the physical contact and responded by kicking the aggressor away. Staff intervened to separate the residents and emergency medical technicians were called to the scene. The assaulted resident did not sustain physical injuries but expressed fear and discomfort about sharing a room with the aggressor. Staff confirmed that the incident involved one resident hitting another and acknowledged that it met the definition of abuse. The incident was reported to the State Survey Agency, and facility documentation corroborated the sequence of events, including the lack of injury and the emotional impact on the assaulted resident.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the mandated timeframe for one resident. According to the facility's policy, allegations of abuse, including physical altercations between residents, must be reported to the administrator immediately and to the state agency within two hours if there is alleged abuse or serious bodily injury. In this incident, a resident with schizophrenia and a history of traumatic brain injury was forcefully shoved and thrown against a wall by another resident with dementia and delirium. Staff intervened and separated the residents, and the incident was documented in the facility's FRI. However, the FRI was not submitted to the State Agency within the required timeframe. The LPN involved was new and unfamiliar with the FRI process, so she sought assistance from the DNS and another nurse, which contributed to the delay. The DNS confirmed that she was in contact with the LPN multiple times regarding the incident, but acknowledged that the report was not completed and submitted as mandated.
Failure to Ensure Resident Access to Bedside Light
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of borderline personality disorder was found to be unable to independently operate the bedside light in their room due to a short three to four inch chain. The resident reported frustration at being unable to turn the light on or off without assistance, requiring them to use the call bell for help. The resident's care plan did not indicate any need for a shortened chain on the bedside light. Staff interviews revealed inconsistent awareness of the resident's ability to use the light. One CNA believed the resident could use a reacher to operate the light, while an LPN stated the resident was not capable of doing so and frequently called for assistance. The RN Case Manager was unaware of the shortened chain, and the Environmental Services Director explained the chain had been shortened for safety reasons after the resident previously pulled on it to reposition, but was unaware the resident could no longer use the light independently. The Director of Nursing Services confirmed knowledge of the short chain but was not aware the resident required help to operate the light.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. The resident, admitted with diagnoses including anxiety, hallucinations, and disorientation, was prescribed haloperidol as needed for hallucinations or aggression. However, medication administration records, behavior monitoring, and progress notes showed that haloperidol was given on multiple occasions without documented indications for use. Nursing staff administered the medication for reasons such as difficulty sleeping, agitation, or being difficult to control, but did not consistently document the specific behaviors or symptoms that warranted its use. Interviews with several LPNs revealed uncertainty about the reasons for administering haloperidol and a lack of documentation regarding the resident's behaviors or the effectiveness of the medication. The Director of Nursing Services confirmed that haloperidol should only have been given for aggression or hallucinations and that staff were expected to document the specific behaviors, non-pharmacological interventions attempted, and the outcome of the medication administration. The absence of this documentation and the administration of haloperidol without clear indications constituted a failure to prevent the use of unnecessary psychotropic medications and chemical restraints.
Failure to Develop Care Plan Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive care plans that included interventions for the use of psychotropic medications for one resident who was admitted with diagnoses of anxiety, hallucinations, and disorientation. Physician orders for this resident included multiple psychotropic medications such as Buspirone, Lamotrigine, Mirtazapine, Duloxetine, Olanzapine, and Haloperidol, each prescribed for specific symptoms including irritability, mood stabilization, insomnia, depression, and hallucinations. A review of the resident's care plan dated 2/24/25 revealed no documented interventions addressing the use of these psychotropic medications. Additionally, there was no evidence in the resident's health record of any resident-specific interventions related to psychotropic medication use. This lack of documentation was confirmed by the Director of Nursing Services during an interview.
Failure to Timely Assess and Intervene After Choking Incident
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had documented issues with coughing and choking during meals and when swallowing medications. The resident was on a dental/mechanical soft texture diet with nectar thick liquids per physician orders. On one occasion, the resident choked during dinner, requiring the Heimlich maneuver to be performed by an LPN, after which the resident recovered. Despite this significant choking episode, the resident's diet was not immediately downgraded, and there was no evidence that the speech-language pathologist was notified following the incident. The LPN involved acknowledged that the resident's diet should have been changed to puree at the time of the choking event but did not take this action. The Director of Rehabilitation was not informed of the choking incident until three days later, at which point the diet was downgraded and a consultation with the speech-language pathologist was initiated. The Director of Nursing Services also confirmed that the diet should have been downgraded immediately after the choking episode. The delay in assessment and intervention following the resident's change in condition constituted the deficiency.
Failure to Provide Care Planned Smoking Safety Interventions
Penalty
Summary
A deficiency occurred when a resident with Wernicke's encephalopathy and dementia, who was care planned to wear smoking gloves while smoking to prevent burns, was observed smoking in the designated area without the required gloves. The resident's care plan and quarterly smoking evaluation both specified the use of smoking gloves, and the most recent MDS assessment indicated moderate cognitive impairment. During the observation, the resident stated that staff did not offer the smoking gloves, and a CNA confirmed the resident was not wearing them as required. The Director of Nursing Services acknowledged that staff failed to provide the gloves as outlined in the care plan.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with behavioral and emotional care needs, both of whom had diagnoses including PTSD. According to the facility's own Trauma Informed Care Policy, residents should be screened for traumatic events, and individualized care plans should be developed to address trauma triggers and interventions. However, for both residents, there was no evidence in their clinical records that trauma assessments were completed or that care plans addressing trauma triggers were developed. Staff interviews confirmed a lack of awareness regarding the residents' trauma histories or potential triggers, and social services staff acknowledged that required trauma screenings and care planning had not been completed for these residents. One resident, admitted with schizophrenia and PTSD, reported experiencing auditory hallucinations and distress but could not recall being asked about trauma triggers. Staff members were unaware of any specific triggers or interventions in place for this resident. The second resident, admitted with major depressive disorder and PTSD, also had no documented trauma assessment or care plan. This resident stated that no one had discussed the cause of their PTSD or potential triggers, and staff were similarly unaware of any trauma-related needs or interventions. The lack of trauma-informed assessments and care planning placed these residents at risk for re-traumatization.
Failure to Implement Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon a pharmacist's recommendations for a resident who was prescribed Olanzapine, an antipsychotic medication, for hallucinations. The pharmacist had recommended that, if the antipsychotic was to be continued, the medical record should be updated to include a list of symptoms or target behaviors and their impact on the resident, documentation that other causes and medications had been considered, evidence of individualized nonpharmacological interventions, and ongoing monitoring. A review of the resident's clinical record showed that these recommendations were not implemented, as there was no documentation of specific target behaviors, their impact, consideration of other causes or medications, or individualized nonpharmacological interventions. The Director of Nursing Services confirmed that the pharmacist's recommendations were not followed.
Failure to Withhold Unnecessary Medications as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically bowel and antihypotensive drugs. One resident with a diagnosis of hypotension was prescribed midodrine to be administered three times daily, with clear physician orders to hold the medication if the systolic blood pressure (SBP) exceeded a specified threshold. Despite these orders, the medication was administered on at least 24 occasions when the resident's SBP was above the hold parameter, as confirmed by medication administration records and staff interviews. Nursing staff acknowledged that the medication should have been withheld on these occasions but was not. Another resident with a history of bipolar disorder and hip fracture was prescribed senna for constipation, with instructions to hold the medication for loose stools. Review of medication administration and bowel movement records showed that the resident continued to receive senna even after experiencing multiple episodes of loose or watery stools, as indicated by type 6 and type 7 bowel movements. Staff interviews confirmed that the medication should have been withheld until normal stool consistency returned, but this was not done, and the medication was administered daily regardless of bowel movement consistency.
Failure to Provide Ordered Physical Therapy Evaluation for Resident with Frequent Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide therapy services as ordered for a resident with a history of frequent falls and a diagnosis of dementia. The resident had multiple falls in recent months, with eight falls documented in one month, and was known to be impulsive and prone to self-transferring. A physician's order was written for a physical therapy (PT) evaluation due to these frequent falls. However, the PT evaluation was not completed as ordered. Staff interviews revealed that the therapy manager determined PT was not appropriate because the resident had recently completed therapy, but this decision was not discussed with the resident's provider. Further review showed that the interdisciplinary team assumed the provider was informed of the decision to not proceed with the PT evaluation, but there was no evidence of direct communication with the provider regarding the appropriateness of the order. The failure to follow the physician's order for a PT evaluation left the resident without the specialized rehabilitative services that had been deemed necessary to address their risk for falls.
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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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