Windsor Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Oregon.
- Location
- 820 Cottage Street Ne, Salem, Oregon 97301
- CMS Provider Number
- 385224
- Inspections on file
- 21
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Windsor Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with CHF and weakness, who was cognitively intact, did not have access to a call light overnight after receiving a bed bath. The call light was later found clipped to the top corner of the mattress and not within reach. The resident reported that no staff checked on them during the night despite needing to use the toilet and subsequently experienced fecal incontinence in bed. A CNA and an LPN confirmed the resident’s upset condition related to the inaccessible call light, and the Administrator acknowledged the lack of call light access and stated that staff were expected to check on residents at least every two hours.
A resident with a right leg fracture stabilized by an external fixator and diabetes had an order for PRN oxycodone 5 mg every four hours for pain, but the controlled substance record showed the last dose was given and the supply depleted, and the medication was not reordered in a timely manner. The resident later reported severe pain (rated nine), yet the MAR showed no oxycodone was administered and the record lacked documentation of any alternative pain interventions while staff attempted to obtain more medication from the pharmacy and the on-call provider.
A hospice resident with COPD exacerbation and respiratory failure had PRN orders for oral morphine for SOB and moderate to severe pain but, according to multiple staff interviews and record review, an LPN refused to administer the ordered morphine during a period when the resident was screaming, anxious, disoriented, and exhibiting terminal agitation and SOB. Staff reported that the LPN declined to medicate the resident due to concern about depressing respirations, would not call hospice or the physician, and refused to provide the med cart keys to another LPN who attempted to follow the physician’s orders. CNAs and another LPN described the resident as having a very bad night with ongoing pain and distress, while the hospice care manager noted frustration with ordered medications not being administered and confirmed morphine was appropriate for the resident’s symptoms.
A resident with dementia and a history of falls was repeatedly kept up in a wheelchair at the nurse’s station for most of the night by an LPN, despite the resident’s stated desire to go to bed and the absence of any care-plan directive to keep the resident up all night. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN ordered them to get the resident back up, refilled the resident’s coffee, and positioned the resident with a blanket, coffee, and magazines at the nurse’s station, stating she did not want to complete more incident reports for falls. Other nursing staff told the LPN this was abusive, and leadership later confirmed that keeping a resident at the nurse’s station all night for staff convenience was not acceptable, constituting involuntary seclusion.
Two residents experienced alleged abuse or neglect that was not reported to the State Survey Agency as required. One resident with COPD and respiratory failure had an order for PRN morphine for shortness of breath and pain, but an LPN allegedly refused to administer the medication despite reports of screaming, dyspnea, and anxiety, and no FRI was filed despite the Administrator and a unit manager being aware. Another resident with a hip fracture and dementia was allegedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and the Administrator allegedly instructed staff not to submit an FRI, with no investigation or report completed.
The facility failed to investigate two separate allegations of potential abuse and neglect. In one case, a resident with COPD and respiratory failure was reportedly denied ordered pain medication by an LPN despite reports of screaming, shortness of breath, and anxiety, and no investigation or documentation was completed to determine what occurred or rule out abuse/neglect. In the second case, a resident with a hip fracture and dementia was reportedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and again no investigation or documentation was completed despite leadership being notified.
Two residents did not receive care according to physician orders: one did not receive ordered repeat x-rays for ongoing pain and was later found to have a fracture, while another received a narcotic pain medication on a scheduled basis instead of as needed due to a transcription error, with a delay in starting the medication. The errors were acknowledged by the Resident Care Manager.
The facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation. A cook was observed plating meals without a hair restraint, contrary to the US FDA Food Code 2022, which requires all staff to wear hair restraints regardless of hair length. This oversight placed residents at risk for unsanitary food conditions.
The facility did not complete annual performance reviews for two CNAs, which are essential for ensuring competent nurse staffing. A review of personnel records showed that one CNA, hired in 2022, had not been reviewed since early 2024, and another, hired in 2016, had not been reviewed since mid-2023. The DON confirmed the oversight, potentially risking resident care due to insufficiently assessed staff competence.
The facility failed to involve residents in the development of their comprehensive care plans. A resident with diabetes reported not being informed about medication or treatment changes, and another resident with a hip fracture did not receive a care plan copy. Staff confirmed that while initial meetings were held, no care planning meetings occurred post-comprehensive MDS, leaving residents uninvolved in their care plan development.
A resident with a hip fracture was admitted with a urinary catheter, which was supposed to be removed a week after discharge per hospital orders. Despite instructions for a trial of voiding and a urology referral, the facility did not document any attempt to remove the catheter or make the referral. The resident was observed with the catheter still in place and unaware of any removal plan. Staff confirmed the failure to follow up on the orders.
A facility failed to change a PICC dressing for a resident receiving IV antibiotics, as the dressing change was not listed on the MAR and staff were unaware of the required frequency. The dressing, last changed on March 4, was overdue for a change on March 11, leading to a deficiency in care.
A facility failed to timely implement a physician's order to reduce a resident's Trazodone dose from 150 mg to 100 mg. The order, recommended on 10/21 and confirmed on 11/5, was not executed until 1/1, placing the resident at risk for unnecessary psychotropic medication use.
Expired medications, including Healthy Eyes (Leutin) and Terbinafine, were found in a medication room, confirmed by an LPN and the DNS. These expired medications should not have been available for resident use, posing a risk for diminished treatment efficacy.
A resident with diabetes and pressure ulcers received wound care that did not follow proper infection control practices. An LPN failed to perform hand hygiene after removing contaminated gloves during a dressing change, contrary to the facility's infection control policy. The LPN acknowledged the oversight, and the infection preventionist confirmed the requirement for hand hygiene between glove changes.
A facility failed to offer a pneumonia vaccine to a resident admitted with hypertension, as revealed during an interview and record review. The resident was eligible for the vaccine, but the medical record showed no indication of it being administered or offered. The DNS confirmed the oversight upon reviewing the resident's medical record.
Failure to Ensure Accessible Call Light Resulting in Incontinence Episode
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was accessible throughout the night. A cognitively intact resident with diagnoses including congestive heart failure and weakness was admitted on 2/27/26. A Facility Reported Incident dated 2/26/26 documented that the resident received a bed bath on the evening of 2/23/26 and the call light was not accessible until the following morning. The resident reported that no one checked on them during the night and that they needed to use the toilet. On the morning of 2/24/26 at approximately 7:40 AM, a CNA found the resident’s call light button clipped to the top corner of the mattress and untucked from under the pillow, and the resident was very upset after experiencing fecal incontinence in bed because they were unable to call for assistance. An LPN confirmed being informed that the resident was upset after the incontinence episode due to the inaccessible call light, and the Administrator acknowledged that the resident did not have access to the call light and experienced fecal incontinence. The Administrator also stated that staff were expected to check on residents at least every two hours during the shift.
Failure to Provide Ordered PRN Pain Medication After Supply Depletion
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with significant pain needs. The resident was admitted with a right tibia and fibula fracture stabilized with an external fixator and had diabetes. A physician’s order dated 10/23/25 directed that the resident receive oxycodone 5 mg every four hours as needed for pain. The admission MDS Pain CAA indicated that pain interventions were to be administered per provider orders. The controlled substance record showed the last oxycodone dose was given on 10/25/25 at 7:35 PM, with zero tablets remaining afterward. On 10/27/25 at 6:00 AM, the Treatment Administration Record documented the resident reported a pain level of nine, yet the Medication Administration Record showed no oxycodone 5 mg was administered that day. On 10/27/25, an LPN documented that the resident complained of pain and requested oxycodone 5 mg, but the facility was out of the medication. The LPN contacted the pharmacy to reorder and requested a Cubex pull code, which the pharmacy denied because remaining oxycodone from the original prescription was already packaged for delivery and a new prescription was required for further refills. The LPN left a voicemail for the on-call provider, and later documented that the provider faxed a new prescription and that three additional tablets would be delivered, with approval to pull from Cubex if needed. The medical record contained no documentation of when the oxycodone was actually delivered and no documentation of any additional pain-management interventions provided to the resident after the reported pain level of nine. A pharmacy technician later stated that four tablets of oxycodone 5 mg were delivered to the facility on 10/27/25 at 3:55 PM, and the DNS confirmed the resident’s oxycodone supply had been depleted on 10/25/25 and was not reordered timely.
Failure to Administer Ordered Morphine for Hospice Resident in Distress
Penalty
Summary
The deficiency involves the facility’s failure to protect a hospice resident with COPD exacerbation and respiratory failure from neglect when ordered morphine for pain and shortness of breath was not administered. The resident had a physician’s order for morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. Progress notes documented that the resident experienced COPD exacerbation, groaning, difficulty breathing, thirst, distress, rapid breathing, anxiety, and difficulty swallowing. The medication administration record showed the resident received one dose of morphine on 11/6/25 at 8:38 PM, with no further doses given that day despite ongoing symptoms. Multiple staff interviews indicated that the LPN assigned to the resident’s care refused to administer the ordered morphine despite reports from other staff that the resident was screaming, anxious, short of breath, disoriented, and exhibiting terminal agitation behaviors such as pulling off clothes, screaming, and crying. Staff reported that the LPN stated she did not want to depress the resident’s breathing and would not listen to other staff, would not call hospice or the physician, and refused to give the medication cart keys to another LPN who attempted to medicate the resident per orders. CNAs and another LPN described the resident as having a very bad night, being in pain and distress the whole shift, and stated they believed the resident was being neglected. The hospice care manager reported hospice staff were frustrated with medication administration not being done as ordered and confirmed that morphine was appropriate for shortness of breath and could benefit the resident by slowing rapid breathing. The LPN later stated she did not remember if she gave the medication and did not provide further documentation or explanation.
Resident Kept at Nurse’s Station Overnight Against Wishes to Avoid Fall Reports
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion by keeping the resident up in a wheelchair at the nurse’s station for most of the night against the resident’s expressed wishes. The resident was admitted in 2025 with diagnoses including a hip fracture and dementia, and the care plan dated 12/2025 did not include any intervention to keep the resident at the nurse’s station all night to prevent falls. Despite this, on at least one night, the resident was kept at the nurse’s station until approximately 2:00–2:30 AM, provided incontinence care, and then returned to the nurse’s station and kept there until 5:00 AM, even though the resident requested to go to bed and did not usually stay up at night. Multiple staff interviews described that an LPN insisted on keeping the resident up at the nurse’s station because the resident had a history of falls and the LPN did not want to complete additional incident reports. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN intervened and directed them to get the resident back up, despite the resident stating a desire to remain in bed. Staff observed the resident’s coffee cup being repeatedly refilled at night, which they stated was not normal for this resident, and the resident was positioned at the nurse’s station with a table, coffee, and magazines while being kept awake. Other nursing staff reported that on more than one night the LPN attempted to keep the resident up at the nurse’s station, tucking a blanket around the resident in the wheelchair and leaning the chair back while the resident stated being tired and wanting to go to bed. Staff stated they informed the LPN that forcing the resident to remain in the chair at the nurse’s station instead of allowing the resident to go to bed was abusive. The LPN acknowledged keeping the resident up at the nurse’s station due to concerns about falls and incident reports, and facility leadership confirmed that residents could be monitored at the nurse’s station but not for the entire night and not for staff convenience. This conduct resulted in the resident being subjected to involuntary seclusion and not being allowed to go to bed when requested.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse or neglect to the State Survey Agency for two residents. For one resident with COPD, acute exacerbation, and respiratory failure, a physician order dated 11/4/25 directed administration of morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. A former staff member reported that on 11/6/25, an LPN assigned to this resident refused to administer the ordered pain medication despite other staff reporting the resident was screaming, short of breath, and very anxious. The former staff member stated the Administrator was aware of the incident and spoke with the LPN, but no Facility Reported Incident (FRI) was submitted. The Administrator later acknowledged there was no FRI submitted, and the LPN/Unit Manager also confirmed awareness of the incident and that no FRI was reported. For another resident admitted with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to remain in a wheelchair at the nurse’s station for most of the night and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member stated she informed the Administrator of this incident and was told not to submit an FRI because it was handled in-house. The DNS stated there should have been an investigation of this incident and clarified that while residents may be monitored at the nurse’s station, it should not be for the entire night or for staff convenience. The Administrator acknowledged there was no FRI submitted to the State Survey Agency for this incident.
Failure to Investigate Allegations of Abuse and Neglect Involving Two Residents
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse and neglect involving two residents. For one resident with COPD with acute exacerbation and respiratory failure, a former staff member reported that on a specific date an LPN assigned to the resident refused to administer ordered pain medication despite reports from other staff that the resident was screaming, short of breath, and very anxious. The former staff member stated she was not informed of the incident at the time and therefore did not investigate it. The Administrator later acknowledged that no investigation was completed, could not provide any documentation showing an investigation or how abuse/neglect was ruled out, and stated she felt the incident was handled by the facility. The LPN involved stated she did not remember if she gave the medication and would need to check the medical record, but did not provide further information or documentation. Another LPN/Unit Manager confirmed awareness of the allegation that the LPN refused to give the resident morphine despite being told the resident was distressed, and also acknowledged that no investigation was completed. For a second resident with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to stay up in a wheelchair for most of the night at the nurse’s station and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member reported that she notified the Administrator of this incident. The DNS stated there should have been an investigation for this allegation and clarified that while residents could be monitored at the nurse’s station, this should not occur for the entire night or for staff convenience. The Administrator again acknowledged that no investigation was completed for this incident, could not provide any documentation of an investigation, and stated she felt the incident was handled by the facility.
Failure to Follow Physician Orders for X-rays and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents. One resident with peripheral vascular disease was admitted in February 2017 and had a physician order for a right hand x-ray on September 10, 2024. Although the initial x-ray was negative for fracture, the resident continued to experience pain and limited range of motion, prompting repeat x-ray orders on September 18 and September 24, 2024, which were not completed. The resident was later found to have a right wrist fracture during a hospital visit on October 10, 2024. The Resident Care Manager confirmed that the ordered x-rays were not obtained as directed. Another resident, admitted in September 2024 with kidney failure, had a physician order for hydrocodone/acetaminophen 5-325 mg to be given three times daily as needed (TID PRN). The medication was started four days after the order was received and was administered on a scheduled basis (TID) rather than as needed, due to a transcription error. This error was identified in a provider note, which indicated that the incorrect administration may have contributed to the resident's increased confusion. The Resident Care Manager acknowledged the delay in starting the medication and the incorrect administration schedule.
Failure to Ensure Kitchen Staff Wore Hair Restraints
Penalty
Summary
The facility failed to ensure that kitchen staff wore appropriate hair restraints during meal preparation, as observed on March 12, 2025. Specifically, a cook was seen plating meals without a hair restraint, which is a violation of the US FDA Food Code 2022. The Dietary Manager initially stated that there was no requirement for hair restraints for staff with hair less than half an inch long. However, upon reviewing the food code, it was confirmed that all staff, regardless of hair length, are required to wear hair restraints to prevent hair from contacting exposed food. This oversight placed residents at risk for unsanitary food conditions.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two Certified Nursing Assistants (CNAs) out of a sample of five, which was necessary for assessing sufficient and competent nurse staffing. Specifically, the personnel records review on March 14, 2025, revealed that Staff 9, hired on December 5, 2022, had not received a performance review since January 10, 2024. Similarly, Staff 12, hired on May 26, 2016, had their last performance review on June 8, 2023. This oversight was confirmed by the Director of Nursing, who acknowledged that the annual performance reviews for these staff members were not completed, potentially placing residents at risk due to a lack of competent staff.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to involve residents in the development of their comprehensive care plans, as evidenced by the experiences of three residents. Resident 15, admitted with a diagnosis of diabetes, reported that no one discussed medication or treatment changes with them, and they did not have a care planning meeting. Staff 16, the Interim Social Services, confirmed that while a 72-hour care meeting was conducted upon admission, no care planning meeting was held after the initial comprehensive MDS was completed. Staff 17, the Interim MDS Coordinator, admitted to only asking about pain and not involving residents in the care plan development. Staff 2, the DNS, stated that while she updated the care plan as needed, the MDS staff were responsible for updates post-comprehensive MDS, and residents were not involved in the development process. Similarly, Resident 32, also with a diagnosis of diabetes, stated they did not have a care planning meeting, did not receive a copy of their care plan, and were not involved in discharge decisions. Resident 42, readmitted with a hip fracture, also reported not having a care planning meeting or receiving a copy of their care plan. Staff 16, 17, and 2 provided consistent accounts of the lack of resident involvement in care plan development, confirming that the facility did not conduct care planning meetings with residents after the comprehensive MDS was completed, thus failing to include them in the process.
Failure to Assess and Follow Up on Urinary Catheter Removal
Penalty
Summary
The facility failed to ensure proper assessment and follow-up for the removal of a urinary catheter for a resident admitted with a hip fracture. The hospital discharge order specified that the catheter should be removed one week after discharge, and a progress note indicated a trial of voiding should be attempted when acute symptoms improved, with a referral to a urologist for further evaluation. However, the medical record lacked documentation of any attempt to remove the catheter or to make a urology referral. On observation, the resident still had the catheter in place and was unaware of any plan for its removal. Staff confirmed the oversight, acknowledging that the catheter removal and urology referral were not attempted as ordered.
Failure to Change PICC Dressing as Scheduled
Penalty
Summary
The facility failed to complete IV dressing changes for a resident who was receiving antibiotics through a PICC line. Resident 39, admitted with an abdominal wall abscess, had a physician's order for zoxyn, an IV antibiotic, every six hours. The resident also had an unscheduled order for PICC line care, with the next dressing change due on January 27, 2025. On March 14, 2025, an LPN stated she did not change the PICC dressing because it was not listed on the MAR and was unaware of the frequency for changing PICC dressings. Another LPN, the Resident Care Manager, confirmed that PICC dressings should be changed weekly and as needed but could not find the last recorded dressing change for the resident. Upon observation, the dressing was dated March 4, 2025, indicating it was overdue for a change on March 11, 2025.
Failure to Implement Timely Dose Reduction of Psychotropic Medication
Penalty
Summary
The facility failed to ensure the gradual dose reduction of psychotropic medications as ordered for one of the sampled residents. Resident 2, who was admitted with a diagnosis including diabetes, had a physician's order on 9/26/24 for Trazodone 150 mg, which was later discontinued on 12/31/24. A recommendation was made on 10/21/24 to reduce the Trazodone dose to 100 mg, and the provider responded with an order to implement this reduction on 11/5/24. However, the facility did not implement the order until 1/1/25, as confirmed by Staff 2 (DNS) during a review on 3/12/25. This delay in implementing the physician's order placed the resident at risk for unnecessary psychotropic medication use.
Expired Medications Found in Facility's Medication Room
Penalty
Summary
The facility failed to ensure that medication rooms were free of expired biologicals, which was observed in one of the two sampled medication rooms. During an inspection, two expired medications, Healthy Eyes (Leutin) and Terbinafine (an antifungal medication), were found in the medication storage room. Staff 13, an LPN, confirmed the presence of these expired medications and acknowledged that they should not be administered to residents. Additionally, Staff 2, the Director of Nursing Services (DNS), also confirmed that the medications were expired and should not be given to residents. This oversight placed residents at risk for diminished treatment efficacy.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with pressure ulcers. The resident, admitted in February 2017 with a diagnosis of diabetes, had a physician's order dated March 5, 2025, for wound care on the buttocks. On March 11, 2025, during an observed dressing change, an LPN performed hand hygiene, donned gloves, cleaned the wound, but then failed to perform hand hygiene after removing the contaminated gloves before applying new ones. The LPN acknowledged the omission, stating that hand hygiene was completed only at the beginning and end of the dressing change. The facility's infection preventionist confirmed that hand hygiene should be performed every time gloves are removed.
Failure to Offer Pneumonia Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumonia vaccine, which was identified during an interview and record review. The deficiency involved a resident who was admitted to the facility in December 2024 with a diagnosis of hypertension. Upon reviewing the resident's medical record, it was found that the resident was eligible for a pneumonia vaccine but was not offered one. On March 13, 2025, at 11:11 AM, the Director of Nursing Services (DNS) confirmed that there was no indication in the medical record that the pneumonia vaccine was administered prior to admission or offered after admission to the facility.
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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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