Avamere Rehabilitation Of Newport
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport, Oregon.
- Location
- 835 Sw 11th Street, Newport, Oregon 97365
- CMS Provider Number
- 385162
- Inspections on file
- 13
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Newport during CMS and state inspections, most recent first.
Inadequate staffing and poor coordination between dietary and nursing staff led to routine delays in meal service, with meal carts arriving up to 74 minutes late and impacting timely diabetic medication administration. Staff reported insufficient communication about delays and a lack of clear expectations for meal service timing.
Surveyors identified unsanitary conditions in the kitchen, including a cabinet door with exposed wood and removable paint, a detached baseboard with inaccessible debris, and an ice machine installed without a required air gap and surrounded by black debris. The Dietary Manager and Corporate Maintenance acknowledged these issues and improper installation practices.
A facility did not ensure that a resident was fully informed about the binding arbitration agreement at admission. The Medical Records Director incorrectly explained that the resident could still go to court if their rights were violated, which contradicted the actual terms of the agreement. The Administrator confirmed that the information provided to the resident was not accurate.
A resident with a history of stroke and aphasia, but cognitively intact, had important preferences for bathing and bedtime that were not documented in the care plan. Staff interviews revealed inconsistent awareness of these preferences, resulting in the resident being awakened earlier than desired and causing distress. The lack of clear documentation and communication led to the resident's choices not being consistently honored.
A resident with a history of stroke and hypertension had their Metoprolol held multiple times due to low blood pressure, but the physician was not notified as required by orders. Review of records and staff interviews confirmed the lack of provider notification and documentation, despite facility expectations for communication in such cases.
A resident with hemiplegia and a history of stroke was found to have long, jagged, and dirty fingernails and toenails, despite being dependent on staff for ADLs. Staff indicated that nail care was provided on shower days and as needed, but the resident's nails had not been trimmed for at least two weeks, resulting in unaddressed hygiene needs.
A resident with a history of stroke and aphasia, identified as at risk for skin impairment, developed a 5 cm dark lesion on the scalp. Despite care plan instructions and the resident expressing concern, staff did not monitor or document changes to the lesion, and no follow-up was recorded. Staff interviews confirmed awareness of the lesion but a lack of monitoring and documentation.
A resident with depression and recent suicidal ideations was not provided with an updated behavioral health care plan or safety interventions following a hospital evaluation. CNAs were unaware of the resident's mental health status due to lack of information in the Kardex and shift reports, and a required follow-up call to Mental Health was not completed.
A resident with diabetes and diabetic neuropathy was admitted with orders for daily insulin and fasting serum blood sugar (FSBS) monitoring, but FSBS results were not documented for two months. The resident reported infrequent monitoring, and staff confirmed the FSBS order was missed during admission. Staff also stated that FSBS are usually obtained weekly and that nurse managers are expected to review new orders within 24 hours.
The facility failed to ensure hair and beard restraints were worn during meal preparation. Staff were observed preparing food without the required restraints, contrary to the facility's policy. The Dietary Manager acknowledged the requirement for staff to wear these restraints.
The facility failed to ensure a system was in place to offer COVID-19 vaccines to staff. A CNA was not offered the COVID-19 vaccine, nor was there documentation of education related to the vaccine. The Resident Care Manager confirmed that she stopped offering the COVID-19 vaccine to staff in August 2023.
The facility failed to offer pneumonia vaccines to eligible residents, including those with heart disease, lung disease, diabetes, and stroke. Despite being eligible, these residents were not offered additional doses, as acknowledged by the Resident Care Manager.
The facility failed to ensure a resident was shaved, compromising the resident's hygiene. Despite being cognitively intact and expressing a preference for no facial hair, the resident was observed with facial hair on multiple occasions. Staff confirmed the resident should have been shaved but was not, and the Resident Care Manager and DNS acknowledged that staff were expected to shave the resident as soon as possible if missed on a shower day.
A resident with hearing loss was observed wearing only one hearing aid due to the other being broken. Despite informing staff, no appointment was made to fix the broken hearing aid. Staff confirmed the resident should have been wearing two hearing aids and acknowledged the oversight.
A resident with a genetic muscular disease and a contracture of the left hand was observed without the required brace on multiple occasions. The washable part of the brace was taken to the laundry and not returned, making it unavailable. The Resident Care Manager was unaware of the issue and confirmed the resident only had one brace that needed daily application.
The facility failed to follow the care plan for a fall-risk resident with a history of stroke, leaving them unattended in their room in a wheelchair on multiple occasions. Staff were unaware of the care plan requirements, and the Resident Care Manager confirmed the oversight.
Delayed Meal Service Due to Inadequate Staffing and Poor Coordination
Penalty
Summary
The facility failed to provide adequate staffing and coordination for meal service in the kitchen, resulting in significant delays in meal delivery to residents. Scheduled lunch service was to begin at 11:30 AM, but observations showed that meal carts arrived late to dining areas, with the final cart arriving up to 74 minutes after the scheduled start time. Staff interviews confirmed that such delays occurred routinely one to two times per week, with delays lasting up to 45 minutes. Staff responsible for meal preparation and delivery reported being unable to complete tasks on time due to limited personnel and space constraints in the kitchen. Communication between dietary and nursing staff was insufficient, as nursing staff were rarely notified of late meals, impacting the administration of diabetic medications that needed to be given prior to meals. The lack of clearly defined expectations for meal service timing between departments contributed to the ongoing delays. The facility administrator acknowledged the absence of established protocols for meal service timing and emphasized the need for improved teamwork, communication, and kitchen efficiency.
Sanitation and Plumbing Deficiencies in Kitchen Environment
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility kitchen. A white painted cabinet door under the sink in the food preparation area had exposed wood and black marks around the edge, with paint that was easily removed when rubbed. The baseboard under a counter was detached from the cabinet, and black debris was visible between the baseboard and the cabinet in an area not accessible for cleaning. The ice machine was directly plumbed from the outside without a required one-inch air gap, and a metal plate attached to the floor beneath the ice machine had a one-inch-wide rim of black debris around it. The Dietary Manager acknowledged the presence of uncleanable surfaces and improper installation of the ice machine, and Corporate Maintenance confirmed the expectation for a one-inch air gap for correct installation.
Failure to Properly Inform Residents of Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, as required. The facility's Patient and Facility Arbitration Agreement stated that by signing, parties waive their constitutional right to have claims decided in court before a judge and jury. Interviews revealed that all residents had signed the agreement, and the Medical Records Director was responsible for explaining it upon admission. However, the explanation provided to residents was incorrect, as it included information that residents could still go to court if their rights were violated, which contradicts the terms of the binding arbitration agreement. The Administrator acknowledged that the facility was not providing correct information regarding the agreement.
Failure to Communicate and Honor Resident Preferences for Daily Routines
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's preferences regarding bathing and bedtime routines were communicated and honored. The resident, who had a history of stroke and aphasia but was assessed as cognitively intact, placed high importance on their bathing and bedtime preferences. Despite this, the care plan did not document these preferences, and staff interviews revealed inconsistent awareness and understanding of the resident's desired routines. One CNA reported that some staff were unaware of the resident's preference to sleep in, leading to the resident being awakened earlier than desired, which caused distress. Another CNA noted difficulty in understanding the resident's preferences due to the lack of detailed information in the care plan. Further interviews indicated that while the Activities Director had interviewed the resident about preferences, updates were only made to the care plan for recreational activities, not for daily routines such as bathing or bedtime. The Interim DNS/RNCM acknowledged insufficient oversight in ensuring the resident's preferences were addressed and expected a person-centered care plan to be in place. The lack of clear documentation and communication of the resident's preferences placed the resident at risk for not having their choices honored.
Failure to Notify Physician After Holding Antihypertensive Medication
Penalty
Summary
The facility failed to notify the physician after holding blood pressure medication for a resident with a history of stroke and hypertension. Physician orders specified that Metoprolol Tartrate should be held if the resident's blood pressure was less than 100/55, and the physician should be notified for further instructions. Medication administration records showed multiple instances where Metoprolol was held due to low blood pressure readings, but there was no documentation that the physician was notified as required. Interviews with staff revealed that the expected process was to inform the charge nurse and document the event in the provider's communication book. However, review of the communication book showed no entries regarding the held medication for this resident. The interim DNS and the physician assistant both confirmed there was no evidence of provider notification, and the physician assistant stated he would have adjusted the medication dosage if he had been informed of the low blood pressures.
Failure to Provide Timely Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction and left-sided hemiplegia, who was dependent on staff for activities of daily living, was observed to have long, jagged, and dirty fingernails and toenails. The resident reported that their fingernails needed to be trimmed. Staff interviews revealed that nail care was typically provided on shower days, and a CNA stated that nail care for this resident had last been performed two weeks prior. Upon further observation with an LPN Resident Care Manager, the resident's nails remained in poor condition, and it was confirmed that CNA staff were expected to provide nail care during showers and as needed between showers.
Failure to Monitor and Document Resident's Skin Lesion
Penalty
Summary
Facility staff failed to monitor and document changes in a resident's skin condition as required by facility policy. The resident, who had a history of stroke and aphasia but was assessed as cognitively intact, was identified as being at risk for skin impairment. Despite a care plan instructing staff to report and monitor changes in skin condition, a 5 cm dark lesion was noted on the resident's scalp. The resident expressed concern about the lesion through nonverbal cues, but there was no documentation of ongoing monitoring or follow-up in the clinical record after the lesion was initially identified. Staff interviews confirmed that the registered nurse was aware of the scalp lesion but did not monitor it, and the resident care manager was unaware of any further physician follow-up. Weekly skin audits and the treatment administration record did not reflect the presence or monitoring of the lesion. This lack of monitoring and documentation resulted in a failure to provide appropriate treatment and care according to the resident's needs and preferences.
Failure to Update Behavioral Health Care Plan and Communicate Suicidal Ideation
Penalty
Summary
The facility failed to complete a baseline care plan and provide ongoing behavioral health services for a resident admitted with depression who experienced suicidal ideations. After being sent to the hospital for evaluation due to suicidal ideations, the resident returned to the facility, and documentation indicated the resident was not at risk for imminent harm. However, the resident declined to complete a safety plan but agreed to a follow-up call with Mental Health, which was not documented as completed. Interviews with CNAs revealed they were unaware of the resident's recent suicidal ideations, as this information was not included in the Kardex or communicated during shift reports. A review of the care plan and Kardex showed no evidence of a mental health or suicidal ideation care plan or safety interventions. The interim DNS/RNCM was also unaware of the relevant after-visit summary and mental health notes in the chart and confirmed that the care plan and Kardex were not updated and the follow-up call to Mental Health had not occurred.
Failure to Obtain Ordered Fasting Serum Blood Sugars for Diabetic Resident
Penalty
Summary
The facility failed to obtain fasting serum blood sugars (FSBS) as ordered for one resident with diabetes and diabetic neuropathy. Upon admission, the resident had hospital discharge orders for daily insulin injections and FSBS monitoring. A revised care plan also indicated the need for FSBS to be completed as ordered. However, diabetic administration records for two consecutive months showed no documented FSBS results for this resident. The resident reported that FSBS were rarely monitored, and staff interviews confirmed that the hospital discharge order for FSBS was missed during the admission process. Staff also indicated that FSBS were typically obtained weekly for diabetic residents, and nurse managers were expected to review new resident orders within 24 hours to ensure accuracy.
Failure to Use Hair and Beard Restraints During Meal Preparation
Penalty
Summary
The facility failed to ensure hair and beard restraints were worn during meal preparation, as observed on 4/3/24. Staff 13 (Dietary Manager), Staff 14 (Cook), and Staff 15 (Cook) were seen preparing food in the kitchen without hair and beard restraints. Staff 13 indicated that staff were told they were not required to wear hair restraints unless their hair was long and were also told they were not required to wear beard restraints. This was contrary to the facility's policy on Food Handling, revised in 1/2018, which required food and nutrition services staff to wear hair and beard restraints. Staff 13 acknowledged that staff were supposed to wear these restraints while working in the kitchen.
Failure to Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure a system was in place to offer COVID-19 vaccines to staff. Specifically, it was found that a CNA was not offered the COVID-19 vaccine, nor was there documentation of education related to the vaccine. This was confirmed during an interview with the Resident Care Manager, who stated that she stopped offering the COVID-19 vaccine to staff in August 2023.
Failure to Offer Pneumonia Vaccines to Eligible Residents
Penalty
Summary
The facility failed to ensure residents were offered a pneumonia vaccine, placing them at risk for infections. Resident 1, admitted in 2023 with heart disease, received a pneumonia vaccine in 2015 but was not offered another vaccine despite being eligible. Similarly, Resident 9, admitted in 2017 with lung disease, received a pneumonia vaccine in 2016 but was not offered another dose despite eligibility. Staff 6, the Resident Care Manager, acknowledged these oversights on 4/3/24 at 9:19 AM. Resident 11, admitted in 2018 with diabetes, refused a pneumonia vaccine in 2018 but was not offered additional vaccines thereafter. Resident 13, admitted in 2018 with a stroke, received a pneumonia vaccine in 2013 but was not offered another vaccine despite being eligible. Staff 6 also acknowledged these deficiencies. The failure to offer pneumonia vaccines to these residents was identified through interviews and record reviews.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to ensure a resident was shaved, which compromised the resident's hygiene. Resident 4, who was admitted in 2023 with a diagnosis of a stroke and was cognitively intact, expressed a preference for no facial hair and required staff assistance to shave on shower days. On multiple occasions, Resident 4 was observed with facial hair despite being assisted with showers. Staff 4 confirmed that the resident should have been shaved but was not. The Resident Care Manager and DNS acknowledged that if a resident was not shaved on their shower day, staff were expected to shave the resident as soon as possible and not wait for the next scheduled shower day.
Failure to Assist Resident with Hearing Aid Device
Penalty
Summary
The facility failed to assist a resident with a hearing aid device, leading to a deficiency. Resident 30, who was admitted in 2023 with a diagnosis of hearing loss, was observed on multiple occasions to have difficulty hearing staff and her/his roommate. The resident was wearing only one hearing aid, and upon interview, stated that the other hearing aid was broken and that staff had been informed but no appointment was made to fix it. Staff members confirmed that the resident was supposed to wear two hearing aids and acknowledged that the broken hearing aid should have been reported to the Resident Care Manager or Social Services for repair.
Failure to Apply Brace for Resident with Contracture
Penalty
Summary
The facility failed to apply a brace for a resident with a genetic muscular disease, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, who had a contracture of the left hand, was observed without the required brace on multiple occasions. A CNA reported that the washable part of the brace was dirty and taken to the laundry, but it had not been returned, making the brace unavailable for use. The Resident Care Manager was unaware of the missing brace and confirmed that the resident only had one brace, which needed to be applied daily.
Failure to Follow Care Plan for Fall-Risk Resident
Penalty
Summary
The facility failed to provide care and services as care planned for a resident who was at risk for falls due to a stroke, incontinence, gait/balance problems, and left-sided paralysis. The resident's care plan indicated that they should not be left unattended in their room while in a wheelchair. However, the resident was observed unattended in their room in a wheelchair on multiple occasions. Interviews with CNAs revealed that they were not aware of the care plan requirement. The Resident Care Manager acknowledged that the resident was a fall risk and should not have been left unattended, confirming that staff were not following the care plan.
Latest citations in Oregon
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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