Ashland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Oregon.
- Location
- 135 Maple Street, Ashland, Oregon 97520
- CMS Provider Number
- 385197
- Inspections on file
- 24
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Ashland Post Acute during CMS and state inspections, most recent first.
A resident with a UTI experienced changes in condition and was transferred to the hospital on two occasions without documentation that their representative was notified. The DNS confirmed that family notification was required but did not occur in these instances.
Two residents were discharged without adequate coordination or verification of post-discharge support. One was sent home without confirming the availability of a friend to assist or assessing home safety, resulting in exposure to unsafe living conditions. Another was discharged with incomplete instructions, missing a follow-up appointment due to outdated paperwork. Staff did not ensure all necessary information and resources were provided prior to discharge.
A resident with depression was administered Lexapro without being informed of the medication's risks and benefits, and no signed consent was documented. The DNS confirmed that the required information was not reviewed and consent was not obtained.
A resident who was cognitively intact and unable to eat due to a feeding tube was repeatedly brought to the dining room during meal times, despite expressing distress and a desire not to attend. Family complaints were made, and staff acknowledged that this practice was undignified and inappropriate.
The facility did not provide proper wound care or ongoing assessment for a resident with a surgical incision, resulting in wound dehiscence and emergency transfer. Additionally, another resident's use of a power wheelchair was restricted without a formal assessment or documentation, despite care plan changes and staff concerns about safety.
A resident with a history of a left femur fracture and a stage 2 sacral pressure injury experienced a deterioration of the wound to an unstageable, infected state. Despite this change, staff did not notify the provider or update the care plan with new interventions, and the resident was subsequently hospitalized for the infected wound.
Due to a sudden reduction in CNA staffing after several were sent home for COVID-19, only one CNA was left to care for an entire wing, resulting in delayed meal delivery for residents on transmission-based precautions, late administration of scheduled pain medication, and missed personal care such as showers. Staff interviews confirmed that supervisory personnel were not promptly notified of the staffing shortage, leading to significant delays in meeting residents' needs.
Staff did not routinely check or maintain the chemical sanitizer levels in the kitchen's low temperature dish machine, resulting in the machine operating without the required sanitizer. The sanitizer solution container was found empty, and testing confirmed the sanitizer level was below the required standard.
A resident with a stroke history and mental health diagnosis was started on Depakote as a mood stabilizer without obtaining consent or reviewing the medication's risks and benefits, despite being cognitively intact. Staff did not secure consent because the drug was classified as an anti-seizure medication, even though it was used for mental health treatment.
Three residents experienced unmet needs related to their environment, including a resident not provided with a suitable bed despite complaints, another resident unable to be safely transferred due to lack of space in a shared room, and a third resident repeatedly left without access to a call light after care. Staff interviews and observations confirmed these issues, which were not addressed according to care plans or resident requests.
A resident who was cognitively intact and admitted with a stroke was not offered information about advance directives (AD), and there was no documentation in the medical record to indicate that AD information was provided or discussed. Staff confirmed that the new care conference form lacked a section to document the offer of AD information, resulting in a failure to follow facility policy.
A resident with PTSD and insomnia continued to receive Ambien nightly despite a psychologist's recommendation to transition to an alternative sleep aid. The resident was open to the change, but staff did not follow up on the recommendation, and the regional nurse later confirmed the medication had not been discontinued as directed.
A resident with a history of mental health disorders and behavioral concerns did not have PASRR II recommendations incorporated into their care plan. The care plan was not updated to include interventions such as providing books, art supplies, memory cues, or Crisis Team contact information, and staff interviews revealed a lack of follow-through in implementing these recommendations.
Three residents did not have individualized care plans addressing their specific needs: one resident's care plan lacked details about preferred times for incontinence care despite known preferences and refusals, another resident on hospice had no documentation of meaningful activities despite an assessment identifying them, and a third resident approved for independent smoking had no care plan for the management or storage of smoking materials, leaving staff unclear about safety procedures.
Two dependent residents did not receive meaningful activities tailored to their interests, as care plans lacked specific information and staff were unaware of individual preferences. One resident, cognitively intact and interested in group activities, was not informed about or encouraged to participate in events, while another resident on hospice with dementia spent extended periods in their room without engagement, as staff did not know what activities to offer.
Two residents did not receive appropriate follow-up care as ordered or requested. One resident with respiratory symptoms did not have timely nursing assessments or prompt communication of x-ray results showing pneumonia, leading to delayed intervention and hospitalization. Another resident and their family requested a urology appointment, but staff failed to schedule it despite being responsible for medical appointments.
A resident with a history of stroke and high fall risk, who required two staff and a mechanical lift for transfers, was left alone in a wheelchair after therapy while staff sought assistance. The resident attempted to self-transfer and fell. The facility did not complete the fall investigation or update the care plan to address this risk for over two weeks, delaying new interventions.
A resident with heart failure and kidney disease requested a dental appointment during a care conference, and the care plan noted oral health problems requiring staff coordination for dental care. Despite these needs and repeated requests, the responsible staff member did not schedule the appointment, and the regional nurse confirmed that immediate follow-up was expected.
A resident with a history of stroke and heart disease, who required meal assistance, was left waiting with a meal tray while food became cold due to delayed staff response and lack of communication about assistance needs. Observations also found that meal carts were left unattended and a test tray was served cold, indicating that food was not consistently served at safe and appetizing temperatures. Staff interviews confirmed inconsistent documentation and communication regarding meal assistance, leading to delays in meal service.
A resident with respiratory failure and chronic pain had a grievance submitted by family regarding concerns with oxygen administration, meal assistance, pressure ulcer care, and missing items. The facility did not document timely investigation or communicate findings to the complainant before a scheduled meeting, and the grievance policy lacked a clear timeline for resolution.
A resident with a history of spinal surgeries and chronic pain did not consistently receive scheduled showers or safe transfer assistance as outlined in their care plan. Staff failed to document or communicate missed showers, and a CNA used an improper bear hug transfer technique, leading to reported pain. There was no effective system in place to track missed ADL care or ensure staff followed updated care plans.
A resident with arthritis did not receive scheduled doses of Norco for pain due to a delay in obtaining a new prescription, resulting in missed medication administrations. Staff and pharmacy records confirmed the prescription was not sent promptly, and the DON was unaware of the issue.
A resident in palliative care with moderate cognitive impairment requested assistance with toileting but was told by a CNA to use their incontinence brief instead. The facility's Administrator intervened, ensuring the resident received the necessary help. The incident was reported, and the CNA was placed on administrative leave.
A facility failed to accurately assess MDS for a resident with a coccyx pressure ulcer. Despite treatment orders for the wound, both the Admission and Discharge MDS inaccurately indicated no pressure ulcer. This error was confirmed by the DNS, showing a lapse in proper documentation of the resident's condition.
A facility failed to provide necessary treatment information for a resident's coccyx pressure ulcer at discharge. The resident, admitted with diabetes, had a documented pressure ulcer, but the discharge summary lacked treatment details. This was confirmed by the DNS, highlighting a communication lapse with the receiving health care provider.
A resident with heart failure was not offered bathing assistance for over two weeks, as documented in their ADL records. This deficiency was confirmed by the DNS during an interview.
A resident's pressure ulcer was inconsistently assessed and improperly treated, with varying stages identified and inappropriate treatment ordered. The DNS acknowledged the discrepancies and confirmed the incorrect treatment for the wound.
A resident admitted with pressure ulcers had inconsistent and inaccurate documentation in their medical records. The records varied between indicating a Stage III ulcer, a Stage II ulcer, and a Deep Tissue Injury (DTI), with some assessments failing to acknowledge the ulcer entirely. These discrepancies were acknowledged by the DNS, indicating a deficiency in maintaining accurate medical records.
An agency nurse was found impaired and in possession of missing controlled medications intended for two residents, leading to her arrest. The facility staff discovered the misappropriation after observing the nurse's behavior and checking medication supplies. Despite the incident, no residents missed their medication doses.
Failure to Notify Responsible Party of Hospital Transfers
Penalty
Summary
The facility failed to notify the responsible party of a resident regarding two separate hospital transfers related to urinary tract infection (UTI) symptoms and changes in condition. The resident, admitted with a UTI diagnosis, experienced a change in mental status, abdominal pain, and inability to urinate, leading to an emergency department transfer on one occasion. On another occasion, the same resident reported ongoing abdominal pain and was again transported to the hospital for evaluation and treatment. In both instances, there was no documentation in the clinical record that the resident's representative was notified of the hospital transfers. The Director of Nursing Services confirmed that families were supposed to be notified but acknowledged that notification did not occur in these cases.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to ensure safe discharge planning for two residents. One resident, admitted with cellulitis, was discharged home with recommendations for 24-hour care and home health services. However, the facility did not confirm with the resident's identified friend whether assistance would be available, nor did they notify the friend prior to discharge. The resident was discharged without verification of home conditions or provision of resources for in-home caregivers. Upon arrival home, the resident encountered unsafe living conditions, including the presence of rats and lack of running water, and had to seek shelter with a neighbor before being transported to the hospital for further discharge planning. Staff interviews revealed that the facility did not provide the resident with information about the risks of discharging without 24-hour caregivers, did not supply a list of local resources, and did not confirm the availability of the friend to assist post-discharge. Another resident, admitted with a fracture and cognitively intact, was discharged with instructions that included post-discharge appointments. However, the discharge paperwork did not include an updated appointment that was scheduled during a post-operative visit on the same day the discharge instructions were printed. As a result, the resident and family missed an important follow-up appointment. Staff acknowledged that the most current appointment information was not transcribed onto the discharge instruction sheet, leading to incomplete discharge instructions.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident, admitted with a diagnosis of depression, about the risks and benefits associated with the use of Lexapro, an antidepressant medication. A review of the resident's medical record and physician order dated 5/3/25 showed that the resident was receiving Lexapro daily. However, there was no documentation indicating that the risks and benefits of the medication had been discussed with the resident, nor was there a signed consent form for the medication in the record. This was confirmed by the Director of Nursing Services, who acknowledged that the required information had not been reviewed with the resident and that no signed consent was present.
Resident with Feeding Tube Taken to Dining Room During Meals
Penalty
Summary
A resident with a history of stroke and a newly placed feeding tube, who was cognitively intact, was admitted to the facility and was unable to ingest food. Despite being prohibited from eating, the resident was repeatedly taken to the dining room during meal times, where other residents were eating. The resident expressed hunger and a desire not to be present in the dining room during meals, as it caused distress. Family members reported complaints to staff regarding this practice, but the situation continued. A CNA acknowledged that escorting the resident to the dining room under these circumstances was undignified and inappropriate. Facility administration also recognized that this action failed to respect the resident's dignity.
Failure to Provide Wound Care and Assess Power Wheelchair Use
Penalty
Summary
The facility failed to provide appropriate wound care and assessment for two residents. One resident was re-admitted with a surgical neck incision that was almost healed and open to air. Documentation showed conflicting information about whether the incision was covered with a dressing, and there were no orders for dressing changes or ongoing wound assessments after readmission. Staff confirmed that wounds, including incisions, should be monitored weekly and that the resident always had a dressing in place due to a neck brace. However, staff did not recall the wound's appearance prior to a significant event where the incision fully dehisced, resulting in bleeding and emergency hospital transport. The Director of Nursing Services (DNS) acknowledged that staff did not obtain wound care orders or assess the incision after readmission. Another resident, admitted with a diagnosis of seizures and dependent on staff for mobility, had their power wheelchair use restricted due to safety concerns. The care plan was revised to prohibit use of the electric wheelchair, but the clinical record lacked a required Power Mobility Device Screen assessment. Staff interviews revealed that the resident sometimes used the power wheelchair for short periods, but no formal assessment was conducted to determine safety or appropriateness. The DNS confirmed that an assessment should have been completed and findings reviewed with the resident.
Failure to Notify Provider and Update Care Plan for Worsening Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and a stage 2 pressure injury to the sacrum. Upon admission, the care plan addressed the existing pressure ulcer. Over the course of the resident's stay, wound assessments documented a deterioration of the sacral pressure injury, progressing from stage 2 to an unstageable wound with suspected infection. Despite this change, there was no documentation that the resident's provider was notified of the wound's deterioration or suspected infection as of the assessment date when the change was noted. Additionally, the care plan was not updated to reflect the worsening condition of the pressure injury or to include new interventions after the wound became unstageable and appeared infected. Staff interviews confirmed that no provider notification occurred and no new interventions were added to the care plan following the wound's decline. The resident was later admitted to the hospital with an infected unstageable pressure injury to the sacrum.
Failure to Provide Adequate Nursing Staff Resulting in Delayed Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations and staff interviews. On the morning in question, several CNAs were sent home after testing positive for COVID-19, leaving only one CNA to cover an entire wing that typically required four. As a result, food trays for residents requiring transmission-based precautions remained unattended on carts for extended periods, with some residents not receiving their meals until significantly later than scheduled. Staff confirmed that the shortage prevented timely meal delivery and that residents would eventually be fed, but not according to the usual schedule. Additionally, the staffing shortage impacted medication administration. One resident, who was cognitively intact and had a diagnosis of arthritis, did not receive scheduled pain medication (Norco) until more than two hours after the scheduled time. The nurse responsible for medication administration reported being delayed due to the need to reorganize CNA assignments after the staffing shortage, and did not notify supervisory staff for assistance. This delay was confirmed by both the resident and staff involved in the medication pass. The lack of sufficient staff also affected personal care. Another resident, admitted with a history of stroke, did not receive a scheduled shower due to the staffing shortage, as confirmed by the CNA assigned to the wing. The staffing coordinator and DNS both stated they were not notified of the shortage until later in the morning, and the administrator, who was responsible for coordinating additional staffing, was not made aware of the issue until after the shortage had already impacted resident care.
Failure to Monitor and Maintain Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to properly follow dish sanitation practices in the kitchen, as required by professional standards and manufacturer instructions. The low temperature dish machine was supposed to maintain a sanitizer (chlorine) concentration of 50 parts per million. Although staff received training on the operation and chemical requirements of the new dishwasher, observations revealed that staff only monitored the temperature and soap levels, not the chemical sanitizer levels. Staff relied on an outside company to verify chemical levels, and did not perform routine checks themselves. During observation, a cook was seen using the dishwasher without verifying the sanitizer concentration, and the sanitizer solution container was found empty. When the chemical sanitizer level was tested by the administrator, it measured below the required 50 parts per million, and it was confirmed that no sanitizer was connected to the dish machine at that time. This failure to monitor and maintain proper sanitizer levels resulted in noncompliance with food sanitation standards.
Failure to Obtain Consent for Mood Stabilizer
Penalty
Summary
A resident admitted with a history of stroke and a mental health diagnosis was prescribed Depakote, an anti-seizure medication also used as a mood stabilizer. The resident was found to be cognitively intact according to the most recent assessment. Despite this, the facility did not obtain consent for the use of Depakote as a mood stabilizer, nor did staff review the risks and benefits of the medication with the resident. Staff interviews confirmed that consent was not obtained because the medication was classified as an anti-seizure drug, even though it was being used for mental health purposes.
Failure to Accommodate Resident Needs and Preferences in Environment
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in relation to their environment. One resident, admitted after shoulder surgery and at risk for pressure ulcers, repeatedly expressed that their bed was too narrow and uncomfortable, but staff were either unaware of the concern or informed the resident that a larger bed was not available. Another resident, who required a mechanical lift and assistance from two staff for transfers due to a stroke, reported that their shared room lacked sufficient space for safe transfers and wheelchair maneuvering. Staff confirmed that the room setup often required moving the bed at an angle or leaving the door open during transfers, which sometimes compromised privacy. A third resident, with cognitive intactness but impaired extremities from a stroke and heart disease, was observed without their call light within reach after care was provided. The resident stated this was a recurring issue, and staff acknowledged that the call light was not checked or placed within reach before leaving the room, despite care plan instructions. These deficiencies were identified through observations, resident and staff interviews, and record reviews.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident was offered information to formulate an advance directive (AD) as required by its policy. According to the facility's policy, if a resident does not have an AD, the resident or their representative should be given the option to accept or decline assistance in establishing one, and nursing staff are required to document the offer and the resident's decision in the medical record. In the case of a resident admitted with a diagnosis of stroke, the care plan indicated that AD or POLST documentation should be present in the medical record at all times. However, the quarterly social history review noted that the resident did not have an AD, and there was no indication that AD information was offered. Further review revealed that the resident was cognitively intact and, during an interview, stated that no one had discussed ADs with them. Staff interviews confirmed that while residents are typically asked about ADs upon admission and quarterly, and blank forms are offered if needed, the new care conference form no longer included a section to document that AD information was provided. Staff acknowledged that there was no documentation in the resident's record to show that AD information had been offered.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
A resident with diagnoses of PTSD and insomnia was admitted to the facility in September 2023. The clinical psychologist's management plan dated April 16, 2025, recommended transitioning the resident from Ambien, a sedative, to an alternative sleep aid, and noted the resident was open to trying a different medication. Despite this recommendation, medication administration records for April and early May 2025 showed the resident continued to receive Ambien nightly from April 1 through May 7, 2025. On May 8, 2025, the regional nurse confirmed that the resident had not been transitioned off Ambien as recommended and acknowledged that staff had not followed up on the psychologist's recommendation.
Failure to Incorporate PASRR II Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into the care plan. The resident, who was admitted with a history of stroke, mental health disorders, suicidal ideations, and aggressive behavior, had a PASRR II evaluation completed that included specific recommendations such as providing environmental and social structuring, memory cues, art supplies, increased access to books, and the contact information for a Crisis Team. However, the care plan was not updated to reflect these recommendations, and staff did not implement the suggested interventions. Observations revealed that the resident's room lacked books, art supplies, and photos of loved ones, and the resident confirmed not having access to these items. Interviews with staff indicated a lack of clarity and follow-through regarding the handling and implementation of the PASRR II recommendations. The social services staff could not recall what was done with the recommendations, and the resident care manager did not see the PASRR II after its completion. The regional nurse confirmed that staff were expected to review and implement PASRR II recommendations, but this was not done for the resident in question.
Failure to Develop Resident-Centered Care Plans for Incontinence, Hospice Activities, and Smoking
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for three residents with specific needs related to incontinence, hospice activities, and independent smoking. For one resident with arthritis and a history of depression and anxiety, the care plan did not include detailed instructions regarding the resident's preferred times for incontinence care, despite staff and resident reports that the resident was particular about care routines and often refused care from unfamiliar staff. The care plan also did not reflect the resident's current status, as the most recent assessments indicated the resident was cognitively intact and did not refuse care, yet staff interactions revealed ongoing issues with care refusals and unmet incontinence needs. Another resident admitted on hospice with cancer had an activity assessment identifying several meaningful activities, such as reading, listening to music, and being outdoors. However, the care plan failed to specify which activities were important to the resident, and staff were unaware that the care plan did not automatically include these preferences. As a result, CNAs did not have access to information about the resident's preferred activities, limiting their ability to provide individualized, meaningful engagement as identified in the assessment. A third resident, approved for independent smoking, did not have a care plan addressing the management and storage of smoking materials. Staff were unclear about whether the resident was allowed to possess smoking materials or where these items were kept, and the facility had not provided a lock box to secure them. The facility's smoking policy did not address individualized care planning for independent smokers, and staff acknowledged that the lack of a care plan prevented them from ensuring the safety of the resident and others regarding access to lighters and smoking materials.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide meaningful activities for two dependent residents, both of whom were at risk for social isolation. One resident, admitted with anxiety and sepsis and assessed as cognitively intact, expressed interest in group activities such as painting and crosswords, and valued social interaction. Despite this, there was no activity care plan addressing these interests, and the resident did not participate in any activities for 30 days. Staff interviews revealed that CNAs were unaware of the resident's preferences due to the absence of an activity care plan, and the Activities Director did not ensure residents were personally invited or that staff had access to necessary information. The resident was not informed about scheduled group activities and expressed disappointment at missing them. Another resident, admitted on hospice with cancer and dementia, also had an activity assessment indicating a strong preference for reading, music, being outdoors, and group activities. However, the care plan only generically stated staff should escort the resident to activities as desired, without specifying the resident's interests. Over a month, this resident did not attend any activities and was observed spending time in bed or in the room with a CNA present. Staff interviews indicated that resident-specific activities were often not included in care plans, and CNAs did not know what to offer if the resident could not communicate preferences. The Activities Director and DNS acknowledged the lack of meaningful activities and individualized care planning for this resident.
Failure to Assess and Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to properly assess a resident and follow physician orders regarding timely notification and documentation of a significant change in condition. One resident, admitted with arthritis and cognitively intact, underwent a chest x-ray following a physician's assessment due to respiratory concerns. However, there was no nursing assessment documented regarding the resident's respiratory status or the physical condition that warranted the x-ray. The x-ray results, which indicated pneumonia, were available but not promptly communicated to the physician or acted upon. The resident's condition worsened, with increased cough, abnormal lung sounds, and low oxygen saturation, eventually requiring hospitalization. There were no additional nursing assessments documented prior to the escalation of symptoms and hospital transfer. Another resident, admitted with heart failure and kidney disease, and their family requested a urology appointment during a care conference. Despite this request, staff responsible for scheduling medical appointments did not arrange the appointment, and the request was not followed up on. The staff acknowledged the oversight when interviewed, confirming that the appointment had not been scheduled as requested by the resident and family.
Delayed Fall Investigation and Care Plan Update After Resident Fall
Penalty
Summary
A resident with a history of stroke and resulting weakness, who was identified as high risk for falls, was admitted to the facility and required assistance from two staff members and a mechanical lift for transfers. The resident's care plan included interventions such as calling for assistance, keeping the call light within reach, and wearing appropriate footwear. After completing therapy, the resident was left alone in their wheelchair while staff left the room to find additional help for a mechanical lift transfer. During this time, the resident attempted to self-transfer from the wheelchair to the bed and experienced a fall. The facility did not complete the fall investigation in a timely manner, taking over two weeks to finalize the investigation and update the resident's care plan to include assistance back to bed after therapy. Progress notes during this period did not document that the fall was related to being left alone after therapy. Staff interviews confirmed that the investigation and care plan update were not completed within the expected timeframe, resulting in a delay in implementing new interventions to prevent further falls.
Failure to Provide Timely Dental Services After Resident Request
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with diagnoses including heart failure and kidney disease. During a care conference, the resident requested a dental appointment, and the care plan documented oral/dental health problems with instructions for staff to coordinate dental care and transportation as needed. Despite these documented needs and requests, the resident reported that staff had not scheduled the dental appointment after repeated requests. The staff member responsible for making dental appointments acknowledged that the resident's request was made during the care conference but confirmed that the appointment was not scheduled. The regional nurse stated that the expectation was for staff to follow up with a dental appointment immediately when requested by residents.
Failure to Serve Meals at Palatable Temperatures Due to Delayed Assistance and Poor Communication
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for a resident who required assistance with eating and in the kitchen overall. One resident, admitted with a history of stroke and heart disease and assessed as cognitively intact but needing supervision for eating, was observed waiting in bed with a meal tray while her food became cold. Staff interviews revealed that the resident often received meals at her bedside without timely assistance, leading to cold food. The resident's care plan indicated a need for one-person assistance with meals, but this requirement was not reflected on the diet slip or meal ticket, resulting in communication lapses among staff. Staff acknowledged that meal assistance needs were not consistently communicated or documented, and that this contributed to delays in providing timely and warm meals. Additionally, observations showed that meal carts were left unattended and that staff did not always promptly distribute meals. A test tray left in a food cart for 22 minutes was found to have cold broccoli and lukewarm potatoes and meat, confirming that food was not maintained at appetizing temperatures. Staff interviews indicated that there was an expectation for all staff, including nurses, to assist with meal distribution, but this was not consistently practiced. The lack of clear communication, documentation, and timely staff response led to residents receiving food that was not palatable or at a safe and appetizing temperature.
Failure to Establish Timely Grievance Resolution Process
Penalty
Summary
The facility failed to maintain a grievance policy that included a reasonable timeframe for reviewing and resolving grievances, as evidenced by the handling of a grievance submitted on behalf of a resident with respiratory failure and chronic pain. The resident, who was cognitively intact and required assistance with eating, had a physician order for continuous oxygen. A family member submitted a grievance regarding concerns about the resident's oxygen, meal assistance, pressure ulcer interventions, and missing items. The care plan was reviewed and updated, and a meeting was scheduled, but there was no documented communication of findings or updates to the complainant until the scheduled meeting. Staff interviews revealed that the Director of Nursing spoke with a registered nurse about the oxygen issue, but this was not documented in the medical record, nor was the complainant informed of any findings prior to the meeting. The grievance officer only spoke with the complainant at the scheduled meeting, and the facility's policy did not specify a formalized timeline for grievance resolution. The regional nurse expected a response to the complainant within five days, but the facility's process did not ensure timely communication or resolution, and the policy required revision to address these deficiencies.
Failure to Provide Consistent ADL Assistance and Safe Transfers
Penalty
Summary
A deficiency occurred when a dependent resident with a history of respiratory failure, chronic pain, lumbar spinal fusion, and cervical spine surgery did not consistently receive assistance with activities of daily living (ADLs), specifically bathing and safe transfers. Documentation showed that the resident refused a shower on one occasion and received only one shower during a multi-week period, with other scheduled showers not attempted or documented. The resident's care plan required showers on specific days and one-person assistance with transfers, but staff failed to follow this schedule and did not consistently document refusals or communicate missed showers to nursing staff. Multiple staff interviews revealed a lack of a system to track missed showers, inconsistent documentation, and poor communication between CNAs and nursing regarding ADL care. Additionally, the resident reported pain after being transferred by a CNA using a bear hug technique, which was contrary to facility policy and the resident's care plan, especially given the resident's spinal history. Staff interviews confirmed that bear hug transfers were not permitted and that the resident's transfer needs were subject to frequent updates by therapy, requiring staff to review care plans regularly. Some staff were unaware of the resident's medical history and the risks associated with improper transfer methods. The Director of Nursing Services acknowledged that staff were expected to follow care plans for both transfers and scheduled showers, and that nurses should be tracking the completion of these tasks.
Failure to Ensure Timely Availability of Pain Medication
Penalty
Summary
A resident with a diagnosis of arthritis was admitted in June 2021 and was prescribed Norco to be administered every four hours for pain management. On January 30, 2025, the Medication Administration Record (MAR) showed that the resident did not receive Norco at four scheduled times throughout the day. Progress notes indicated that the medication was not available due to a delay in obtaining a new prescription, with staff waiting for delivery and notifying the physician of the missed dose. The physician was faxed for a new prescription later that morning, and the pharmacy confirmed that they did not receive the prescription until that day, after which it was filled. Staff interviews revealed that the process for obtaining new prescriptions involved notifying the nurse when a new order was needed, and the nurse would then request it from the physician. The Director of Nursing Services was unaware of the missed doses and unclear about why the prescription was not sent to the pharmacy following the physician's visit the previous day. The resident was noted to be cognitively intact at the time of the incident.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to treat a resident with dignity and respect, which was identified during an incident involving a resident who required assistance with toileting. The resident, who was admitted for palliative care and had a moderate cognitive impairment, requested help to use the bathroom. However, a CNA instructed the resident to use their incontinence brief instead of providing the requested assistance with a bedpan. This interaction was overheard by the facility's Administrator, who intervened and arranged for the resident to receive the necessary assistance from other staff members. The incident was reported to the State Survey Agency, and the CNA involved was placed on administrative leave pending an investigation.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess Minimum Data Set (MDS) assessments for a resident reviewed for pressure ulcers. The resident was admitted to the facility with diagnoses including diabetes and heart failure and had a coccyx pressure ulcer upon admission. Despite physician orders to treat the coccyx wound throughout the resident's stay, the Admission MDS and Discharge MDS inaccurately indicated that the resident did not have a pressure ulcer. This discrepancy was verified by the Director of Nursing Services (DNS), highlighting a failure in accurately documenting the resident's condition in the MDS assessments.
Failure to Communicate Pressure Ulcer Treatment at Discharge
Penalty
Summary
The facility failed to provide necessary information to continuing care providers regarding the treatment of a coccyx pressure ulcer for a resident at the time of discharge. The resident, who was admitted to the facility in July 2024 with a diagnosis of diabetes, had a documented coccyx pressure ulcer as per the Treatment Administration Records (TARS) from July 2024. However, the Discharge Summary dated July 30, 2024, only noted macerated skin on the coccyx and did not include any treatment information for the pressure ulcer. This omission was confirmed by the Director of Nursing Services (DNS) on August 29, 2024, during an interview, indicating a failure to communicate essential treatment details to the receiving health care provider.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance to a resident who was unable to perform activities of daily living independently. The resident, admitted with a diagnosis of heart failure, was not offered the opportunity to bathe from mid-April to the end of April 2023, as documented in the resident's ADL Bathing records. This deficiency was confirmed by the Director of Nursing Services during an interview conducted in late August 2024.
Inconsistent Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to properly assess and treat a pressure ulcer for a resident, leading to inconsistencies in the staging and treatment of the wound. The resident was admitted with a Stage III pressure ulcer, but subsequent assessments varied, identifying the wound as Stage II, a deep tissue injury (DTI), and unstageable due to slough. These inconsistencies were acknowledged by the Director of Nursing Services (DNS), who noted the discrepancies in the wound assessments. Additionally, the treatment ordered for the resident's wound was inappropriate for the identified stage. The physician's orders included the use of Santyl and a calcium alginate pad, which are not suitable for a Stage II pressure ulcer or DTI. The DNS confirmed that the treatment was incorrect and that the wound was closed upon her visual inspection. These actions and inactions placed the resident at risk for worsening pressure ulcers.
Inaccurate Documentation of Pressure Ulcer in Resident's Medical Record
Penalty
Summary
The facility failed to accurately document the medical records of a resident admitted with pressure ulcers. The resident, who had diagnoses including diabetes and heart failure, was admitted with a Stage III pressure ulcer according to the Admission Assessment. However, subsequent documentation was inconsistent, with a Skin Assessment indicating a Stage II ulcer and treatment orders for a Deep Tissue Injury (DTI). The Care Plan did not acknowledge the presence of a pressure ulcer, and the Admission MDS incorrectly stated that the resident had no pressure ulcers. Further inconsistencies were noted in the resident's medical records, with a Progress Note revealing the wound was unstageable due to slough, while other assessments continued to describe it as a Stage II or DTI. The Nutrition Admission Assessment inaccurately reported the resident's skin as intact, and the Discharge MDS again failed to document the pressure ulcer. These inaccuracies were acknowledged by the Director of Nursing Services, highlighting a significant deficiency in maintaining accurate medical records for the resident's pressure ulcer condition.
Misappropriation of Controlled Medications by Impaired Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, specifically narcotic and sedative drugs, which were intended for two residents. An agency nurse, identified as Witness 1, was observed by other staff members to be impaired while on duty. Upon investigation by the Director of Nursing Services (DNS) and a Resident Care Manager, it was discovered that two bottles of methadone prescribed to one resident were missing, and another resident's Ativan supply was less than documented. Witness 1 was found with the missing methadone bottles in her possession and was subsequently arrested for theft. The residents involved in the incident included one with end-stage kidney disease prescribed Ativan on a PRN basis, and another with burn wounds and liver disease who was receiving scheduled methadone doses. The facility staff, including a Resident Care Manager and an LPN, reported concerns about Witness 1's behavior, noting her impaired state and inability to perform her duties. Despite the misappropriation, it was confirmed that no residents missed their medication doses on the day of the incident.
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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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