Avamere Rehabilitation Of Junction City
Inspection history, citations, penalties and survey trends for this long-term care facility in Junction City, Oregon.
- Location
- 530 Birch Street, Junction City, Oregon 97448
- CMS Provider Number
- 385229
- Inspections on file
- 26
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Junction City during CMS and state inspections, most recent first.
Two residents, one with chronic pain and another with Alzheimer's disease, were subjected to verbal abuse and derogatory remarks by another resident. Staff and the DNS confirmed the inappropriate behavior, which included profanity, name-calling, and offensive comments, but the facility failed to prevent or adequately address these incidents.
A resident with quadriplegia and neuropathic bladder experienced a traumatic Foley catheter placement, followed by infection and hospitalization. The facility did not thoroughly investigate the incident, as the staff member who performed the catheter change was not identified and no witness statement was obtained. Staff interviews revealed uncertainty about who completed the procedure, and the DNS confirmed that a witness statement should have been included.
A resident with dementia and dysphagia, care planned for total assistance and supervision during meals due to behavioral issues, was left unsupervised in the dining room, resulting in a verbal altercation with another resident. Staff interviews confirmed multiple occasions where no CNA was present during meals, despite the care plan requirement for supervision.
The facility did not ensure proper infection control in laundry services, as staff failed to separate soiled and clean linens, used a fabric gown multiple times before cleaning, and lacked training on PPE and disinfectant use. The workflow required staff to move through clean areas after handling soiled linen, and key information on disinfectant dwell times was not accessible.
A resident admitted with an unstageable pressure ulcer and pain was not accurately assessed, as the MDS failed to document the number of unstageable pressure ulcers and left relevant sections incomplete. Documentation did not reflect that the resident was receiving care for a pressure ulcer, and the DNS acknowledged the inaccuracy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed and documented by surveyors.
A resident did not receive the necessary behavioral health care and services required to meet their needs, as the facility failed to provide appropriate behavioral health interventions and support.
Two residents did not receive their scheduled medications, including an antidiabetic and a movement disorder medication, because the drugs were not available at the time of administration. Staff reported that the medications had been ordered from the pharmacy but had not arrived, resulting in a medication error rate above 5%.
Staff did not deliver care or services that were trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Two residents in a LTC facility experienced significant medication errors. One resident received an incorrect dosage of apixaban, leading to a GI bleed and hospitalization. Another resident was mistakenly given another's medications, including antipsychotics and blood pressure meds, but showed no adverse effects. These incidents highlight lapses in medication administration protocols.
A resident with congestive heart failure gave $1200 to a CNA, who admitted to accepting the money despite knowing it was against facility rules. The resident intended $1000 as a loan and $200 as a gift, motivated by the CNA's financial struggles. The incident was reported by another staff member, leading to the CNA's termination.
The facility failed to ensure an RN was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports, and the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, placing residents at risk for inadequate RN oversight and nursing assessments.
The facility failed to maintain appropriate medication storage temperatures for one medication storage refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit. The temperature logs revealed multiple instances of temperatures below the required range of 36-46 degrees F over a three-month period. Staff acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range.
The facility failed to store and handle food in a sanitary manner, with observations of unsealed freezer bags, expired food items, and undated condiments in two unit refrigerators and freezers. The Dietary Manager confirmed that expired items were not discarded.
The facility failed to follow CDC-recommended infection control standards for a resident with head lice. The resident was placed on Enhanced Barrier Precautions instead of contact precautions, and their personal items were not properly laundered or treated. Housekeeping staff did not follow correct PPE protocols, placing other residents at risk.
The facility failed to assist a resident with the formulation of an advance directive, despite the resident's request for assistance. The resident, admitted with depression and bipolar disorder, requested help in November 2023, but no assistance was provided as confirmed by the resident and staff.
The facility failed to maintain clean and functional equipment for two residents. One resident's walker had a loose wheel and worn handle, while another's wheelchair was dirty and had torn armrests. Both issues were acknowledged by staff but remained unaddressed, compromising the residents' environment.
A resident with vascular dementia and bipolar disorder was diagnosed with head lice, but the facility failed to update the care plan promptly. The diagnosis was made on April 2, 2024, and treatment was applied the same day, but the care plan was not updated until April 4, 2024. The DNS acknowledged the delay.
A resident with dementia and muscle weakness, who was moderately cognitively impaired, was found smoking unsupervised despite a care plan requiring supervision. The resident sustained a burn injury after receiving a cigarette from another resident and smoking it independently. The Director of Nursing Services acknowledged that the care plan was not followed.
Failure to Protect Residents from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from verbal abuse by another resident, resulting in two residents being subjected to inappropriate and abusive language. One resident, who was cognitively intact and admitted with chronic pain and muscle weakness, reported that another resident entered their room, used profanity, and called them names. This resident also described a separate incident where the same individual made a derogatory comment while the resident was going to the shower. Staff confirmed that the abusive resident verbally attacked this resident and made fat jokes, and the Director of Nursing Services acknowledged the behavior as inappropriate. Another resident, admitted with Alzheimer's disease and a cognitive communication deficit, was also subjected to verbal abuse by the same resident. During an incident, staff overheard the abusive resident making derogatory statements, including saying that "you people need to go to fucking jail" and referring to others as "fucking crazies." Staff described the behavior as rude and verbally abusive, and the Director of Nursing Services confirmed the inappropriateness of the conduct. The facility did not prevent or adequately address these incidents, resulting in residents being exposed to verbal abuse.
Failure to Investigate Catheter-Related Injury
Penalty
Summary
The facility failed to thoroughly investigate a treatment-related injury involving a resident with quadriplegia and neuropathic bladder who experienced a traumatic Foley catheter placement. The resident was admitted with significant medical needs and was cognitively intact at the time of the incident. On the night the catheter was changed, the resident later developed symptoms of infection, including nausea and elevated temperature, and subsequently became nonresponsive, requiring emergency hospitalization for septic shock. The facility's investigation did not include documentation identifying the staff member who performed the catheter placement or a witness statement from that staff member. Interviews with staff revealed uncertainty about who completed the procedure, and attempts to contact the suspected staff member were unsuccessful. The Director of Nursing Services acknowledged that the investigation should have included a witness statement from the staff involved.
Failure to Provide Supervision During Meals for Resident with Behavioral Needs
Penalty
Summary
Staff failed to provide care and treatment as outlined in the care plan for a resident with dementia and dysphagia who required total assistance and supervision during meals. The care plan specified that the resident was to eat in a designated dining room under supervision due to an easy-chew diet and a history of behavioral issues, including agitation and verbal aggression. On one occasion, the resident and another individual engaged in a verbal altercation in the dining room, and it was confirmed that no CNA was present to supervise at the time, despite the care plan requirement. Multiple staff interviews revealed that there were several instances where no CNA was present in the dining room during meals, including during the incident involving the verbal altercation. Staff acknowledged that supervision was required for the resident's safety, but CNAs alternated supervision due to other responsibilities, leading to lapses in coverage. Facility leadership confirmed that staff should have been present to supervise the resident as outlined in the care plan.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to implement proper infection control standards in its laundry services, as evidenced by observations and staff interviews. Soiled and clean linens were not adequately separated, and staff did not consistently follow standard precautions. A fabric gown used for handling soiled linen was hung in the clean area next to washing machines, and staff would walk through the clean area to access the sink for handwashing after sorting soiled linen. The gown was only cleaned once daily despite being used multiple times a day. Staff were not provided with procedures for the use of personal protective equipment (PPE) in the laundry room, nor were they informed about the required dwell time for the disinfectant cleaner used in the area. Further, staff responsible for laundry services had not received training on handling biohazard waste or soiled linens, and there was a lack of clear guidance regarding the use and effectiveness of the disinfectant cleaner. The Housekeeping Manager acknowledged the need for increased training, and the Director of Nursing Services recognized that the workflow between clean and soiled areas in the laundry room was problematic. The expected information about disinfectant dwell times was not readily available to staff, contributing to improper infection control practices.
Inaccurate Assessment of Pressure Ulcer on Admission
Penalty
Summary
The facility failed to accurately assess a resident admitted with an unstageable pressure ulcer to the buttocks and pain. Upon review, the admission Minimum Data Set (MDS) indicated the resident was at risk for developing pressure ulcers and had one or more unhealed pressure ulcer injuries, but did not document the number of unstageable pressure ulcers due to non-removable dressings or devices. The section of the MDS addressing unstageable pressure ulcers present on admission or re-entry was left incomplete. Additionally, the skin and ulcer treatment section noted the use of a pressure reducing device and surgical wound care, but there was no documentation reflecting that the resident was receiving care for a pressure ulcer. The Director of Nursing Services acknowledged the inaccuracy of the MDS assessment.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified when it was observed that the facility did not provide the required behavioral health interventions or support to meet the needs of its residents, as mandated by regulations. The lack of appropriate behavioral health care and services was noted during the survey, indicating a failure to address residents' behavioral health requirements.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 25 observed medication administration opportunities, resulting in an 8 percent error rate. Specifically, one resident with diabetes and obesity did not receive their scheduled dose of Jardiance because the medication was not available, despite a physician's order for daily administration. Another resident with muscle weakness did not receive their prescribed Ingrezza for a movement disorder, also due to the medication not being available at the time of administration. In both cases, staff reported that the medications had been ordered from the pharmacy but had not yet arrived, leading to missed doses.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence into the care or services provided to residents, as required. The report does not specify the number of residents affected or provide additional details about their medical history or condition at the time of the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving residents. In the first case, a resident was readmitted to the facility with a diagnosis of pulmonary embolism and was prescribed apixaban, an anticoagulant medication. The physician's orders specified a dosage adjustment from 10 mg BID to 5 mg BID after six days. However, the facility failed to implement this dosage change, resulting in the resident receiving an excessive dose of apixaban for an extended period. This error was not identified until a nurse practitioner discovered it, by which time the resident had developed a gastrointestinal bleed, requiring hospitalization and a blood transfusion due to acute blood loss and anemia. In the second incident, a resident with a diagnosis of diabetes was mistakenly administered another resident's medications. The error occurred when a CMA, after being distracted by a request for assistance, inadvertently gave the wrong medications to the resident. The medications included several that the resident was not prescribed, such as antipsychotics and blood pressure medications. Although the resident was monitored and showed no significant adverse effects, the error highlighted a lapse in medication administration protocols. Both incidents underscore the facility's failure to adhere to proper medication administration procedures, resulting in significant medication errors. The first incident involved a failure to adjust medication dosages as per physician orders, leading to a serious health complication for the resident. The second incident involved a mix-up in medication administration, which, although not resulting in immediate harm, posed a potential risk to the resident's health. These deficiencies indicate a need for improved medication management and staff training to prevent future occurrences.
Misappropriation of Resident's Financial Resources
Penalty
Summary
The facility failed to protect a resident from financial exploitation, resulting in a deficiency related to the misappropriation of financial resources. A resident, who was admitted in 2022 with a diagnosis of congestive heart failure, gave $1200 to a CNA at the facility. The resident stated that $1000 was intended as a loan and $200 as a gift. The CNA, identified as Staff 3, admitted to discussing her financial difficulties with the resident and accepting the money, despite knowing it was against facility rules. The incident was reported by another staff member, Staff 5, who was informed by the resident about the transaction. Interviews revealed that Staff 3 was aware of the wrongdoing but felt compelled to accept the money due to her financial situation. The resident expressed a desire to help the CNA, who had mentioned her struggles with paying rent and having three small children. Staff 3 initially claimed to have refused the money but eventually accepted it after the resident insisted. The facility's investigation confirmed the misappropriation, and Staff 3 was subsequently terminated. The incident was reported to the Oregon Board of Nursing and law enforcement.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports from February 1, 2024, through March 31, 2024. The specific dates without RN coverage were February 3, 4, 10, 11, 17, 18, 24, 25, and March 2, 3, 9, 10, 16, 17, 23, 24, 29, 30, and 31. On April 5, 2024, the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, which placed residents at risk for inadequate RN oversight and nursing assessments.
Failure to Maintain Appropriate Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were maintained within parameters for one medication storage refrigerator. The refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit, was observed to have temperatures below the required range of 36-46 degrees F on 19 occasions between January 1, 2024, and April 2, 2024. The temperature logs indicated that the temperatures were to be checked twice daily, but the logs revealed multiple instances of temperatures below 36 degrees F. Staff 2 acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range, as cold temperatures could reduce the efficacy of insulin and vaccines.
Failure to Store and Handle Food Safely
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in two unit refrigerators and freezers. Observations revealed unsealed freezer bags of waffles, expired applesauce cups, ice cream with visible freezer burn, and undated or expired condiments and dairy products. The Dietary Manager acknowledged these observations and confirmed that the expired food items were not discarded as required.
Failure to Follow Infection Control Standards for Head Lice
Penalty
Summary
The facility failed to ensure appropriate infection control standards for a resident diagnosed with head lice. The resident, who was admitted with vascular dementia and bipolar disorder, was found to have live head lice. Despite receiving treatment, the resident was placed on Enhanced Barrier Precautions instead of the CDC-recommended contact precautions. Observations revealed that the resident continued to wear a fabric hat and leather jacket, which were not appropriately laundered or treated as per CDC guidelines. Additionally, housekeeping staff were observed entering the resident's room without following the correct PPE protocols for contact precautions. The Infection Preventionist and Director of Nursing Services acknowledged that the facility did not follow CDC recommendations for managing head lice. The resident's laundry and linens were washed with other residents' items, and the leather jacket and fabric hat were not properly treated. This failure to adhere to infection control standards placed other residents at risk for head lice infestation.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist Resident 10 with the formulation of an advance directive, despite the resident's request for assistance. Resident 10, who was admitted in January 2021 with diagnoses including depression and bipolar disorder, requested help from facility staff to establish an advance directive during a Comprehensive Plan of Care Review in November 2023. However, a review of the resident's clinical record from November 2023 through April 2024 revealed no indication that the facility staff provided the requested assistance. This was confirmed by Resident 10 on April 1, 2024, and acknowledged by Staff 13 on April 2, 2024.
Failure to Maintain Clean and Functional Resident Equipment
Penalty
Summary
The facility failed to ensure resident equipment was clean and in good repair for two residents. Resident 22, who was readmitted with diagnoses including dementia and muscle weakness, was observed using a walker with a loose front wheel and a worn handle missing foam. Despite the resident's statement that the physical therapist was aware of the issues, the walker remained unrepaired. The occupational therapist confirmed the need for repairs, and the administrator acknowledged the deficiencies, including non-functional brakes on the walker. Resident 14, admitted with multiple sclerosis, was observed using a wheelchair that was dirty with dried food debris and had torn armrests exposing the metal underneath. A CNA noted the dirty condition of the wheelchair days prior and was informed that the night shift was responsible for cleaning it. The administrator confirmed the observations of the dirty and damaged wheelchair. These deficiencies placed residents at risk for living in an unhomelike environment.
Failure to Timely Update Care Plan for Head Lice
Penalty
Summary
The facility failed to update the care plan for a resident diagnosed with head lice in a timely manner. The resident, who was admitted in February 2024 with vascular dementia and bipolar disorder, was found to have live head lice on April 2, 2024. The resident's provider was notified, and treatment was prescribed and applied the same day. Despite this, the resident's comprehensive care plan did not include information about the head lice diagnosis until April 4, 2024. The Director of Nursing Services acknowledged that the care plan was not updated promptly.
Failure to Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure supervision and safety interventions were in place to prevent smoking-related accidents for a resident with a history of dementia and muscle weakness. The resident, who was moderately cognitively impaired, had a documented history of smoking in the building, burning herself/himself, and not following smoking rules. Despite the care plan indicating that the resident was to smoke only under supervision and that tobacco and fire materials were to be stored by the facility, the resident was found smoking unsupervised in the courtyard with another resident. This incident resulted in the resident singeing her/his hair and sustaining a burn mark above her/his right eye. On the day of the incident, staff observed the resident smoking unsupervised and noted the burn injury. The resident admitted to receiving a cigarette from another resident and smoking it independently. Staff found several cigarette butts and a pack of cigarettes in the resident's possession. The burn on the resident's forehead was treated and resolved by the following day. The Director of Nursing Services acknowledged that the resident's care plan for supervised smoking was not followed, leading to the incident where the resident burned herself/himself.
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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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