Willowbrook Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pendleton, Oregon.
- Location
- 707 Sw 37th Street, Pendleton, Oregon 97801
- CMS Provider Number
- 385201
- Inspections on file
- 21
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Willowbrook Post Acute during CMS and state inspections, most recent first.
A resident with a history of respiratory failure requested transfer to the hospital after not feeling well, and an LPN documented the transfer in the medical record. However, there was no documentation that the resident’s representative was notified, and the family later reported they only learned of the hospitalization indirectly from a neighbor contacted by the hospital. The DNS confirmed that the representative had not been notified as required.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer medications, was found with open containers of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in a bedside drawer. Record review showed no MD orders, no documented indication for use, and no monitoring for these medications. An RN case manager confirmed there were no orders and that staff did not administer or monitor the creams, while the resident reported self-administering them.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Medication refrigerator temperatures were not consistently monitored or recorded as required, with multiple instances of missed checks and temperatures falling below the acceptable range. Nursing staff and the Environmental Services Director confirmed lapses in monitoring and documentation, and the Director of Nursing Services acknowledged the deficiencies.
The facility did not provide enough nursing staff to meet the care needs of residents, resulting in long call light response times, missed ADL care, and delays in assistance for residents requiring two-person transfers, ostomy care, and other high-acuity services. Staff and residents reported frequent understaffing, especially during night and weekend shifts, leading to incidents such as falls, missed showers, and residents waiting extended periods for help.
A resident prescribed oxycodone for pain management had a card of medication go missing after staff failed to properly count narcotics during shift changes. The medication was not recovered, and the incident was determined to be misappropriation of resident property.
Three residents with moderate cognitive impairment were found with medicated powders and lotions at their bedside without documented assessments or physician orders for self-administration. Staff confirmed that facility policy requires both an assessment and a physician order for residents to self-administer medications, but these steps were not completed, resulting in unauthorized access to medications.
A resident with a history of stroke and one-sided impairment used a motorized wheelchair with a self-releasing seatbelt, but no assessment was completed to determine if the seatbelt functioned as a restraint. Staff interviews revealed uncertainty about whether the resident could independently latch the seatbelt and whether an assessment had been performed, despite facility policy requiring such evaluations.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
A resident with a colostomy did not have a complete, person-centered care plan addressing all aspects of ostomy care, including monitoring for infection, leakage, and proper stoma cleaning. Staff interviews revealed gaps in knowledge and response, leading to an incident of ostomy bag leakage and stoma irritation. The care plan lacked detailed interventions, and both nursing and administrative staff acknowledged these deficiencies.
A resident with severe cognitive impairment and total care needs experienced a fall after a CNA failed to reposition the bed following incontinence care. The incident occurred during a night shift when only two CNAs were assigned to care for 50 residents, which staff and leadership acknowledged was insufficient to meet the residents' high acuity needs.
A resident with Parkinson's disease and mobility issues was prescribed trazodone, a psychotropic medication, without a documented diagnosis or clinical rationale. Despite pharmacy reviews identifying this issue and recommending a diagnosis, the resident continued to receive the medication for nearly a month without appropriate documentation. The pharmacist and DNS confirmed that the pharmacy's recommendation was not addressed in a timely manner.
A resident with significant cognitive impairment and multiple chronic conditions did not receive their scheduled morning medications on time, resulting in a medication error rate of 26.67%. The RN administered the medications over two hours late, and the delay was acknowledged by both the nurse and the DNS.
Staff did not follow enhanced barrier precautions for a resident with a urinary catheter, including failing to don gloves and gowns and neglecting hand hygiene during care. The resident's catheter bag was also placed on the floor, contrary to infection control policy. Staff interviews confirmed knowledge of the required procedures but acknowledged not following them.
A resident with cognitive impairment and a history of aggressive behaviors entered another resident's room and physically abused them, resulting in bruising. The facility failed to implement adequate monitoring or preventive measures to protect residents from such interactions, leading to a substantiated case of abuse.
Three residents did not receive ordered PT, OT, or SLP services as prescribed, including delayed evaluations, missed therapy sessions, and incomplete documentation. Staff and family confirmed therapy was not provided as ordered, with staffing shortages and missed orders contributing to the deficiency.
The facility did not consistently post accurate or complete Direct Care Staff Daily Reports, with 13 days identified where licensed nurse staff hours were either incorrect or missing information, as confirmed by the staffing coordinator.
A resident developed bilateral hand contractures and significant pain due to the facility's failure to prevent the loss of range of motion. Despite initial assessments indicating no upper extremity impairments, the resident's condition worsened over time. The care plan interventions, including the use of a carrot and an edema glove, were not consistently implemented, and the resident rarely received restorative therapy. Staff interviews confirmed the lack of a restorative plan and consistent monitoring, contributing to the resident's decline.
The facility failed to properly label and store food items, maintain a clean kitchen environment, and prevent ice machine contamination. Observations revealed improperly labeled food, unsanitary conditions, and a lack of an air gap in the ice machine's drain plumbing. The Dietary Manager and Administrator acknowledged these issues.
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 25 percent error rate. Errors included late administration of medications for a resident with chronic pain and osteoarthritis, incorrect dosage for a resident with hypertension, and incorrect timing of medications for a resident with Parkinson's disease and a psychotic disorder. These errors were acknowledged by the staff involved and confirmed by the Corporate RN.
The facility failed to provide necessary care and services to maintain personal hygiene for a resident with a fractured femur and moderately impaired cognition. The resident reported not being offered a shower since admission and had to give themselves a bed bath. Staff interviews revealed inconsistencies in following the resident's shower schedule and documenting refusals or attempts to bathe.
A facility failed to monitor and document a resident's skin conditions, leading to unaddressed bruises. Despite policies requiring weekly skin audits, the resident's bruises were not assessed or treated. Staff were unaware of specific handling instructions, and proper documentation was lacking, resulting in a deficiency in care.
The facility failed to implement fall prevention interventions and analyze falls for two residents. One resident's bed was often elevated despite care plan instructions, and another resident experienced two falls without proper incident reporting or analysis.
The facility failed to obtain physician orders and properly maintain respiratory equipment for two residents. One resident received oxygen therapy without a physician's order, and another had an oxygen concentrator set at an incorrect flow rate with a dirty filter. Staff were unclear about their responsibilities for maintaining the equipment.
The facility failed to document a clinical rationale for pharmacy recommendations for two residents. One resident with dementia and mood disorder continued on Abilify without a documented rationale, and another resident with anxiety disorder continued on Celexa and clonazepam without a documented rationale. These actions were acknowledged by the Regional RN.
A resident receiving clonazepam for anxiety disorder did not have gradual dose reductions (GDRs) attempted as required by CMS guidelines. Despite a pharmacist's recommendation and no documented behaviors indicating the need for the medication, the facility failed to attempt GDRs or provide a clinical rationale for the continued use of clonazepam.
The facility failed to follow care plans for two residents, one requiring assistance with bed mobility and another with dentures, leading to unmet needs and potential injury. Staff did not adhere to the care plans, causing pain and neglecting denture assistance.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of the resident’s transfer to the hospital following a change in condition. Resident 3, admitted in February 2026 with a diagnosis including respiratory failure, requested to be sent to the hospital on 3/28/26 because he/she was not feeling well, and an LPN documented the transfer in a progress note. However, there was no documented evidence that the resident’s representative was notified of this transfer. During interview, the resident’s family member reported that the facility did not inform her of the transfer and that she only learned of it the next day from a neighbor who had been contacted by the hospital. The Director of Nursing Services confirmed that the facility did not notify the resident’s representative of the transfer and acknowledged that notification should have occurred.
Failure to Prevent Unauthorized Self-Administration of Non-Prescribed Medications
Penalty
Summary
Surveyors identified that a resident was self-administering non-prescribed topical medications despite a documented determination that they were not appropriate to self-administer any medications. The resident, admitted with hemiplegia, had a Self-Medication Administration Evaluation dated 11/13/25 indicating they were not appropriate to self-administer medications. During an observation on 3/19/26 at 7:50 AM with a RN case manager, open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) were found in the resident’s bedside table drawer. Review of the clinical record showed there were no physician orders for the anti-itch cream, hydrocortisone cream, or DMSO, and the resident did not have an order to self-administer any medications. The RN case manager confirmed the lack of orders for these medications, and at 8:10 AM the resident stated they did self-administer the medications found in their room. This constituted a failure by the facility to ensure the resident did not self-administer non-prescribed medications and to provide treatment and care according to physician orders and the resident’s evaluated ability to self-administer medications.
Unmonitored Self-Administration of Topical Medications Without Physician Orders
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring, indication for use, or physician orders for multiple medications. A resident admitted with hemiplegia in May 2024 had a self-medication administration evaluation dated 11/13/25 indicating they were not appropriate to self-administer any medications. During an observation on 3/19/26, an RN case manager found an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in the resident’s bedside table drawer. Record review showed no physician orders, no documented indication for use, and no monitoring for these medications. The RN case manager confirmed the resident did not have orders for the anti-itch cream, hydrocortisone cream, or DMSO, and that staff did not administer or monitor these medications. The resident stated they self-administered the medications found in their room, despite the prior evaluation determining they were not appropriate to self-administer any medications.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Monitor and Maintain Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper storage and monitoring of medication refrigerator temperatures, as evidenced by review of temperature logs and staff interviews. The logs for July and August 2025 showed that temperatures were not consistently checked and recorded twice daily as required, with 15 instances where the temperature was checked only once or not at all. Additionally, there were 12 occasions when the refrigerator temperature fell below the acceptable range of 36°F to 46°F. Staff interviews confirmed that nurses were responsible for monitoring and documenting refrigerator temperatures each shift, and that out-of-range temperatures should be reported and addressed. The Environmental Services Director acknowledged that the refrigerator had been running low for several weeks and that multiple readings were below the required minimum. The Director of Nursing Services also confirmed the missed checks and out-of-range temperatures on the logs.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On a day when the census was 53 residents, staffing lists showed a significant number of residents required two-person assistance for transfers, bathing, toileting, and dressing, as well as one-to-one feeding assistance and bariatric care. On a specific night shift, only two CNAs were present for 50 residents, which staff and family members confirmed was inadequate to meet resident acuity needs. This staffing shortage was directly linked to incidents such as a resident fall and delays in care. Throughout several days of observation, call light response times were excessively long, with some call lights going unanswered for up to 47 minutes. Residents were observed waiting for assistance with activities of daily living (ADLs), including toileting and going to bed, for extended periods. Some residents reported waiting up to two hours for help, and staff confirmed that chronic understaffing led to missed showers, delayed care, and inability to complete rounds or provide timely assistance. The lack of functioning call light monitors and staff not carrying required devices further contributed to delays in care. Specific residents experienced negative outcomes due to insufficient staffing. One resident with an ostomy reported multiple incidents where their ostomy bag burst due to delayed assistance, resulting in soiling themselves and their bed. Another resident, dependent on staff for all ADLs, reported long waits for care, especially during night shifts. Staff interviews consistently indicated that staffing was based on state minimum ratios rather than resident acuity, and that frequent call-offs and lack of agency coverage exacerbated the problem. Resident Council meeting minutes and direct resident feedback highlighted ongoing concerns with slow call light response and staff not returning after initial contact.
Misappropriation of Controlled Pain Medication Due to Improper Narcotic Counting
Penalty
Summary
A deficiency occurred when a card of oxycodone, a Schedule II controlled pain medication prescribed to a cognitively intact resident with an abdominal wall infection, was found missing during a routine narcotic count. The investigation revealed that certified medication aides (CMAs) and nurses on the night shift were not properly counting the narcotic drawer, which led to the loss of the resident's medication. The missing medication was not found, and the facility determined that misappropriation of the resident's property had occurred. Interviews confirmed that the resident was unaware of any missed doses and had not experienced any interruption in receiving needed pain medication. Staff involved in the narcotic count reported the missing card and acknowledged that the medication was likely thrown away by mistake due to improper counting procedures. The incident was substantiated as misappropriation of resident property following the facility's internal investigation.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to safely self-administer medications. For three residents with moderate cognitive impairment and various diagnoses, including dementia, bipolar disorder, and gastroparesis, surveyors observed medicated powders and lotions at the bedside without documentation of a self-administration assessment in the health records. In each case, there was no evidence that the residents had been evaluated for their capacity to self-administer these medications, nor were there physician orders authorizing self-administration. Staff interviews confirmed that medications were present at the bedside and that facility policy required both a physician order and an assessment for self-administration. Staff acknowledged that these requirements had not been met for the residents in question, and that medications should not have been accessible to residents without proper evaluation. The lack of assessment and unauthorized access to medications constituted the deficiency identified by surveyors.
Failure to Assess Resident for Use of Physical Restraint
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was appropriately assessed for the use of a physical restraint. The resident, who had a history of stroke and was impaired on one side, used a motorized wheelchair with a self-releasing seatbelt. According to the facility's policy, an evaluation should be completed prior to the initiation of any device that could function as a restraint, as well as annually and upon a change of condition. However, a review of the resident's electronic medical record revealed that no assessment was completed regarding the use of the seatbelt when the resident used the motorized wheelchair. Observations over several days showed the resident moving throughout the facility in the wheelchair with the seatbelt in place. Interviews with the resident and multiple staff members indicated that the seatbelt was used for safety, but the resident could not latch it independently, though they could unlatch it. Staff confirmed that an assessment was required in such cases to determine if the seatbelt was functioning as a restraint, but were unsure if one had been completed. The Director of Nursing Services was unaware of the seatbelt use until recently and stated that assessments should be completed quarterly to ensure the seatbelt was not acting as a restraint.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Develop Comprehensive Ostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing all aspects of ostomy care for a resident with a colostomy. The care plan in place did not include specific interventions for monitoring signs and symptoms of infection, leakage, or instructions on cleaning the stoma and peristomal skin. Documentation showed that the resident required assistance with ostomy care, and staff interviews revealed that some staff were not fully aware of the necessary procedures or were slow to respond, resulting in an incident where the ostomy bag leaked and caused irritation to the resident's stoma. Staff interviews confirmed that certified nursing assistants (CNAs) and nurses were expected to review the care plan and report any concerns related to ostomy care, but the care plan lacked detailed interventions. The resident, who was cognitively intact, expressed concerns about infection and leakage, and staff acknowledged that the care plan did not adequately address these needs. The Director of Nursing and the nurse case manager both reviewed the care plan and recognized the deficiencies in the interventions related to ostomy care.
Failure to Prevent Avoidable Fall Due to Inadequate Supervision and Staffing
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of stroke, and total dependence for care experienced a fall. The resident was admitted with diagnoses including dysphagia and was identified as a high fall risk. On the night of the incident, only two CNAs were scheduled to care for 50 residents. After one CNA changed the resident's brief, the bed was not pushed back against the wall as required. Approximately 30 minutes later, the resident was found on the floor between the bed and the wall, yelling and crying to get staff attention. The resident did not sustain injuries and refused hospital evaluation. Interviews with staff and a family member confirmed that the fall resulted from the failure to reposition the bed after care and that staffing levels were insufficient to meet resident needs, especially given the high acuity of the population. Both CNAs and facility leadership acknowledged that only two CNAs were present during the shift, which was not adequate for the number of residents and their care requirements.
Failure to Address Pharmacy Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication management were addressed by the physician for one resident reviewed for unnecessary medications. Specifically, a resident with Parkinson's disease and difficulty walking was prescribed trazodone, an antidepressant, without a documented diagnosis or clinical rationale for its use. Pharmacy reviews in both June and July identified the lack of an appropriate diagnosis for the new psychotropic medication and recommended that a diagnosis be provided. Despite these recommendations, the resident continued to receive trazodone for 29 days without the required documentation. Interviews with the facility's pharmacist confirmed that monthly reviews were conducted to ensure appropriate clinical diagnoses for all medications, including psychotropics, and acknowledged the absence of a diagnosis for trazodone. The Director of Nursing Services also recognized a delay in documenting clinical rationales for medications and confirmed that the pharmacy's recommendation was not followed up on in a timely manner.
Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, as required, with eight errors out of 30 opportunities, resulting in a 26.67 percent error rate. On one occasion, a resident with significant cognitive impairment and multiple diagnoses, including Parkinson's Disease, was not administered their scheduled morning medications at the prescribed time. The medications, which included carbidopa/levodopa, allopurinol, aspirin, cholecalciferol, finasteride, senna, furosemide, and metoprolol, were due at 7:00 AM but were not given until 9:06 AM. The late administration was acknowledged by the RN responsible and the Director of Nursing Services.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) for a resident with a urinary catheter who required total assistance with activities of daily living. The facility's policy required staff to don gloves and gowns and perform hand hygiene when providing care to residents on EBP, especially during activities such as transferring and toileting. During observation, a certified nursing assistant (CNA) assisted the resident to the commode without performing hand hygiene or donning gloves and a gown. The CNA also placed the resident's catheter bag on the floor before hanging it on the commode. Another staff member entered to assist, donned gloves but not a gown, and after assisting, removed gloves and performed hand hygiene, while the first CNA left the room without performing hand hygiene. Interviews with both staff members confirmed their awareness of the EBP requirements and acknowledged their failure to follow proper infection control procedures, including the use of personal protective equipment and hand hygiene. The director of nursing services also confirmed that all residents on EBP require staff to adhere to infection control practices and that catheter bags should not be placed on the floor. These lapses in protocol placed residents at risk for transmission of infection.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with vascular dementia and peripheral vascular disease, who refused cognitive assessment, was subjected to abuse by another resident diagnosed with a femur fracture and Alzheimer's disease. The second resident, who had severe cognitive impairment and a history of physical and verbal behaviors, wandered into the first resident's room, demanded the resident leave their bed, and pinched the resident's wrist, resulting in two small bruises. The incident was substantiated as abuse by facility staff, and the affected resident expressed distress and requested to be kept away from the aggressor. Staff interviews confirmed that the aggressive resident was known to exhibit physical aggression and had previously scratched and hit staff members. At the time of the incident, there were no specific interventions in place, such as one-on-one supervision, to prevent the aggressive resident from interacting with other residents. Staff responded to the incident after it occurred, but prior to the event, monitoring and preventive measures were insufficient to protect the resident from abuse.
Failure to Provide Ordered Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services, including physical, occupational, and speech therapy, as ordered for three residents who required these services. One resident with a history of stroke, hemiparesis, and dysphagia was admitted with orders for SLP and OT evaluations and treatment. However, the SLP evaluation was delayed by 16 days and the OT evaluation by 19 days after admission. Furthermore, the resident did not receive the prescribed frequency of SLP and OT treatments for two out of four weeks, with staff confirming the lack of adequate therapy staffing as the cause. Another resident with chronic pain syndrome and bilateral hip arthritis was readmitted from the hospital with orders for PT and OT evaluation and management. The electronic health record showed no evidence that these evaluations were completed, and the resident confirmed not receiving the therapy services as ordered. Staff acknowledged the orders were missed but could not provide a reason for the omission. A third resident with hemiplegia and aphasia had orders for PT, OT, and SLP evaluations and treatments. The therapy schedules indicated multiple missed sessions across all three disciplines, with staff citing therapist absences and lack of documentation for the missed sessions. Family members and staff confirmed the resident did not receive therapy as frequently as ordered, and the administrator acknowledged the missed sessions.
Inaccurate and Incomplete Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 13 out of 77 days reviewed. A review of the DCSDRs from 6/1/25 through 8/18/25 revealed that on specific dates, the postings either contained inaccurate licensed nurse staff hours or had missing/incomplete information. This was confirmed during an interview with the Human Resources/Payroll/Staffing Coordinator, who verified the inaccuracies and incomplete postings on the identified days.
Failure to Prevent Loss of Range of Motion and Development of Contractures
Penalty
Summary
The facility failed to prevent the loss of range of motion and the development of contractures for a resident, resulting in bilateral hand contractures and significant pain. The resident was admitted with spinal stenosis and initially had no upper extremity impairments. However, over time, the resident developed weakness and impairments in both arms, which were documented in various medical notes and evaluations. Despite these observations, there was no evidence in the resident's clinical record indicating that the impairments were comprehensively assessed or that ongoing monitoring and exercises were provided to maintain or improve the resident's range of motion or prevent further declines. The resident's care plan included the use of a carrot in the right hand and an edema glove on the left hand, but these interventions were not consistently implemented. Observations and interviews revealed that the resident rarely received restorative therapy, and staff were often unaware of the care plan details or failed to provide the necessary interventions. The resident and a witness reported that the resident experienced significant pain in her/his hands and that the prescribed interventions were not being offered regularly. Staff interviews confirmed the lack of a restorative plan and the absence of consistent monitoring and assessment of the resident's contractures. Several staff members acknowledged that the resident's contractures had worsened and that the resident frequently complained of pain. The facility's failure to implement and monitor the care plan interventions, as well as the lack of a restorative program, contributed to the resident's decline in functional status and increased pain.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, maintain a clean and sanitary environment for food preparation, and prevent potential contamination of the ice machine. Observations in the kitchen revealed partially-consumed containers of various condiments and sandwiches that were not labeled or dated correctly, making it impossible to determine their freshness. Additionally, a pork loin was observed thawing above chicken, posing a risk of cross-contamination. The Dietary Manager acknowledged these issues and stated that the labeling should include the year and that meats should be positioned to thaw at the bottom of the refrigerator to prevent dripping on other items. Further observations identified unsanitary conditions in the kitchen, including dust and grit on supply shelves, accumulated fuzz and dust on ceiling support beams and pipes, and a weathered, oxidized dome covering a test tray. The ice machine in the 200 hall was found to drain directly into the floor plumbing without an air gap, and the ice scoop holster contained standing water with black dust particles. The area around the ice machine was also observed to be unsanitary, with used PPE, black grime, and debris in a puddle of water. The Administrator acknowledged these issues and understood the need for an air gap in the ice machine's drain plumbing to protect against potential backflow from the sewer line.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 25 percent error rate. This was observed through multiple instances of late or incorrect medication administration. For Resident 6, who has chronic pain and osteoarthritis, gabapentin and Voltaren gel were administered significantly later than the prescribed times on two separate occasions. Staff 12 and Staff 13 both acknowledged the late administration of these medications. Additionally, Resident 32, who has hypertension, received only one spray of Ipratropium Bromide nasal solution instead of the prescribed two sprays. Staff 13 acknowledged this error upon review of the physician order. Lastly, Resident 14, diagnosed with Parkinson's disease and a psychotic disorder, received carbidopa levodopa and Seroquel at incorrect times, with the evening dose of Seroquel being administered in the afternoon. Staff 16 acknowledged the short duration between doses and the incorrect timing of the evening medication. These medication errors were confirmed by Staff 2 (Corporate RN) who acknowledged the identified errors for all three residents. The errors included late administration of medications, incorrect dosage, and incorrect timing of medication administration. These deficiencies placed the residents at risk for adverse medication side effects and pain.
Failure to Maintain Personal Hygiene for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident admitted with a fractured femur and moderately impaired cognition. The resident reported not being offered a shower since admission and had to give themselves a bed bath. Observations confirmed the lack of proper bathing supplies at the resident's bedside. The resident's care plan indicated they needed extensive assistance for bathing, with scheduled showers every Monday and Thursday evening. However, records showed no documentation of showers, bed baths, or attempts to bathe the resident on specific dates. Interviews with staff revealed inconsistencies in following the resident's shower schedule and documenting refusals or attempts to bathe. CNAs and LPNs acknowledged the expectation to document all bathing activities and refusals, but there was no record of such documentation for the resident in question. The Regional RN confirmed the expectation for the resident to be bathed on scheduled days and as requested, but this was not adhered to, leading to the deficiency.
Failure to Monitor and Document Resident's Skin Conditions
Penalty
Summary
The facility failed to monitor and document the skin conditions of a resident, leading to unaddressed bruises and potential unmet care needs. The resident, admitted in April 2024 with multiple diagnoses including acute respiratory failure with hypoxia, had multiple bruises and dry, discolored skin on both upper extremities. Despite the facility's policy requiring weekly full-body skin audits and documentation of any skin impairments, the resident's bruises were not assessed, treated, or monitored as per the policy. The resident's clinical records did not indicate any monitoring or treatment of the bruises, and the Treatment Administration Record (TAR) did not reflect the presence of these bruises. Observations and interviews revealed that the resident had dark purple bruises on both hands and forearms, which were not being monitored. Staff members, including CNAs and nurses, were either unaware of the specific handling instructions for the resident's skin or had not documented the bruises properly. The RN and LPN confirmed that the bruises should have been monitored and documented, and an incident report should have been completed. The lack of proper assessment and monitoring of the resident's bruises was a clear deviation from the facility's policy, leading to a deficiency in care.
Failure to Implement Fall Prevention and Analyze Falls
Penalty
Summary
The facility failed to implement fall prevention interventions and evaluate and analyze resident falls for two residents. Resident 23, admitted with spinal stenosis, was identified as a high fall risk with a history of self-transferring and falling. Despite care plan instructions to keep the bed in the lowest position and use a bedside fall mat, observations revealed the bed was often elevated to waist height, and the fall mat was not in place. Staff acknowledged the care plan was not being followed, placing the resident at risk for injury. Resident 32, admitted with rhabdomyolysis and severe cognitive impairment, experienced two falls on the same day. The facility failed to complete Fall Incident Reports for both falls, and there was no evidence of risk identification, evaluation, or root cause analysis. Staff confirmed the lack of documentation and investigation, which is required for every fall. This failure to follow protocol and implement necessary interventions placed the resident at risk for further injury.
Failure to Obtain Physician Orders and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to obtain physician orders, ensure respiratory equipment was properly maintained, and administer oxygen as ordered for two residents. Resident 32 was observed receiving oxygen therapy without a physician's order or a care plan directing staff on how to monitor or administer the oxygen. Staff confirmed the absence of a physician order and care plan for Resident 32's oxygen therapy, despite the resident wearing oxygen daily as per the staff's observations and statements. Resident 28, who was admitted with acute respiratory failure with hypoxia, was observed receiving oxygen at an incorrect flow rate and with a concentrator filter covered in a thick layer of dust. Staff were unclear about their responsibilities regarding the maintenance and cleaning of the oxygen concentrator filters. The resident's oxygen concentrator was set to deliver 2.5 liters per minute instead of the ordered 2 liters, and the filter had not been cleaned as required. Staff confirmed the discrepancies and the lack of clarity on who was responsible for cleaning the filters.
Failure to Document Clinical Rationale for Pharmacy Recommendations
Penalty
Summary
The facility failed to document a clinical rationale for pharmacy recommendations for two residents reviewed for unnecessary medications. Resident 24, who was admitted with diagnoses including dementia and mood disorder, had been receiving Abilify since May 2023. The pharmacist recommended a gradual dose reduction (GDR) as per CMS guidelines, but the physician signed off on continuing the medication without providing a clinical rationale. This omission was acknowledged by the Regional RN on May 16, 2024. Similarly, Resident 3, admitted with an anxiety disorder, had been receiving Celexa and clonazepam. The pharmacist also recommended a GDR for these medications, but again, the physician signed off on continuing the medications without providing a clinical rationale. This was also acknowledged by the Regional RN on May 16, 2024. These actions placed the residents at risk for unnecessary medication administration.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medication
Penalty
Summary
The facility failed to attempt gradual dose reductions (GDRs) for a resident who had been receiving clonazepam 0.5 mg twice daily for anxiety disorder since their admission in 2012. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, GDRs should be attempted in two separate quarters during the first year and annually thereafter unless clinically contraindicated. Despite these guidelines, the resident's clinical record revealed no dose changes or GDRs were completed, and there was no clinical rationale documented to support the continued use of clonazepam. The pharmacist had recommended assessing the resident for GDR, but this recommendation was not followed. Additionally, behavior monitoring records from a one-month period showed no documented behaviors for the resident, further questioning the necessity of the continued medication. The Corporate RN acknowledged the lack of documented behaviors and the failure to attempt a GDR or provide a clinical rationale for the continued use of clonazepam.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement the plan of care for two residents, leading to unmet needs and potential injury. Resident 139, who was admitted with bilateral femur fractures and had a care plan requiring extensive assistance by two staff members for bed mobility, experienced an incident where a CNA independently provided bed mobility and ADL care, causing pain. This incident was reported and investigated, revealing that the CNA did not follow the care plan, and the facility's administrator acknowledged awareness of the incident and the expectation for staff to follow care plans. Resident 32, admitted with severe cognitive impairment and requiring assistance with dentures, was observed multiple times without dentures in their mouth. Despite the care plan indicating the need for assistance with dentures, staff failed to ensure the resident wore them. One CNA found the dentures in a soaking cup, and another CNA, unfamiliar with the resident, did not assist with dentures based on incorrect information from other staff. The LPN and Regional RN confirmed the expectation for staff to follow the care plan regarding dentures.
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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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