Avamere Rehabilitation Of Oregon City
Inspection history, citations, penalties and survey trends for this long-term care facility in Oregon City, Oregon.
- Location
- 1400 Division Street, Oregon City, Oregon 97045
- CMS Provider Number
- 385125
- Inspections on file
- 22
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Oregon City during CMS and state inspections, most recent first.
A resident with limited mobility and a neck fracture, who required two-person assistance for transfers, was injured when a CNA attempted to transfer the resident alone from the commode. This failure to follow the resident's care plan resulted in a fall and a fractured right arm, as confirmed by facility staff and medical records.
Surveyors observed that a CMA pre-prepared and stored multiple residents' medications in plastic cups labeled only with room numbers in a medication cart, including in the narcotic drawer, rather than storing them in their original packaging and locked compartments as required. The DON confirmed this was not proper medication storage.
A resident receiving duloxetine and Wellbutrin for depression was not informed of the risks and benefits of these psychotropic medications, as confirmed by the DON and a review of the medical record.
A resident with asthma and congestive heart failure was found to have a large section of missing sheet rock and debris behind their bed, resulting from the bed hitting the wall. The damage, which had been present for several months, was not repaired despite staff and maintenance being aware of the issue. The Administrator confirmed the repair was not completed in a timely manner.
A resident with a history of major depressive disorder and PTSD, who was cognitively intact, reported that staff mocked her delusions on multiple occasions. Although the resident shared these concerns with Social Services, no documentation or investigation occurred because the resident feared retaliation and did not want to file a grievance. The administrator was not informed of the allegations, resulting in a failure to investigate the reported mental abuse.
A resident with schizoaffective disorder, bipolar type, and probable developmental delay did not receive a required PASARR Level II assessment for serious mental illness and intellectual/developmental disability, despite recommendations and supporting documentation. Social services staff were unaware of the need to request the assessment, and the administrator confirmed it was not completed.
A resident with hearing impairment was left without properly fitting or working hearing aids, despite repeated reports to staff and documentation of the issue. Staff interviews revealed that the devices had not functioned since admission, and social services did not take steps to repair or replace them, resulting in the resident being unable to hear adequately.
A resident with limited mobility and a history of pleural effusion was not provided restorative services to maintain or improve range of motion after discharge from PT, despite expressing interest and being identified as a good candidate. Staff interviews revealed the resident was not enrolled in the restorative program due to a full caseload and lack of follow-up, resulting in the resident not receiving ROM exercises.
Staff did not consistently follow transmission-based precautions for a resident with C. diff, including entering the room without PPE, failing to perform hand hygiene after contact, and allowing the resident to ambulate in common areas despite isolation requirements. Staff interviews confirmed knowledge of the protocols, but adherence was lacking.
A facility failed to properly prepare a resident with depression, anxiety, alcohol abuse, and cannabis dependence for a facility-initiated discharge. The resident was given a list of assisted living facilities but lacked sufficient preparation and orientation. After being absent for over 24 hours, the resident was discharged AMA without medications. Staff confirmed the discharge was facility-initiated, and the Administrator was unaware that an AMA discharge required resident initiation.
A facility failed to follow physician's orders for a resident with diabetes, resulting in a deficiency in medication management. The resident had specific insulin orders requiring physician notification if blood glucose levels exceeded 351, but the facility did not notify the physician on nine occasions when levels were above this threshold. Staff acknowledged the oversight, which placed the resident at risk for complications.
The facility failed to provide palatable food to residents, risking unmet nutritional needs. Residents with various medical conditions reported dissatisfaction with the food quality, describing it as tough, spicy, and lacking flavor. Test trays confirmed these issues, with meals being unpalatable and not served at appetizing temperatures. Staff members also noted poor food quality, confirming residents' complaints.
Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
A resident with a history of neck fracture and limited mobility was admitted to the facility and required a two-person assist for transfers during toileting, as documented in the care plan. Despite this, a CNA attempted to transfer the resident alone from the commode, resulting in the resident slipping and falling to the floor. The fall led to a fracture of the resident's right arm. The resident was cognitively intact at the time, with a BIMS score of 15 out of 15, and was aware of the care plan requirements for two-person assistance during transfers. Interviews and record reviews confirmed that the CNA did not follow the resident's individualized care plan, which specifically required two-person assistance for transfers and toileting. Facility staff, including the RCM and Administrator, acknowledged that the failure to adhere to the care plan directly led to the resident's fall and subsequent injury. The incident was substantiated by the facility's investigation and the resident's hospital discharge summary, which documented the right arm fracture resulting from the fall.
Improper Storage and Pre-Preparation of Medications in Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage of biologicals and medications in accordance with its own policies and accepted professional standards. During observation, six plastic medication cups containing medications and labeled only with resident room numbers were found in the top drawer of a medication cart, and an additional unlabeled medication cup with pills was found in the narcotic locked box of the same cart. These medications were pre-prepared for administration to multiple residents, including those receiving medications such as atorvastatin, gabapentin, sertraline, simvastatin, docusate, topiramate, dicyclomine, prazosin, senokot, trazodone, buspirone, Tylenol, calcium supplements, icosapent, baclofen, Prilosec, hydroxyzine, risperdal, sucralfate, morphine, dilaudid, aripiprazole, mirtazapine, and tamsulosin. A certified medication aide (CMA) acknowledged that she routinely prepped scheduled medications early and left them in the medication cart, labeling the cups with room numbers and placing them in the top shelf or narcotic drawer. She stated this was her usual process due to challenges in administering medications in a timely manner, and admitted it was not best practice. The Director of Nursing confirmed the presence of pre-prepped medications in the cart and acknowledged that this was not proper medication storage.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A resident admitted with a diagnosis of depression was prescribed duloxetine and Wellbutrin, both antidepressant medications, as indicated in the physician orders and medication administration record. Despite receiving these medications daily, there was no documentation in the medical record that the resident had been informed in advance about the risks and benefits associated with either medication. During an interview, the Director of Nursing confirmed that the resident had not been provided with this information.
Failure to Maintain a Homelike and Safe Resident Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who had been admitted with asthma and congestive heart failure. The resident's care plan included interventions to minimize exposure to asthma triggers. However, a large section of sheet rock was missing from the wall behind the resident's bed, with debris and dust scattered on the baseboard and floor. The resident reported that the damage was caused by the bed hitting the wall and that it had not been repaired. Staff interviews confirmed that the wall had been in disrepair for at least five and a half to eight months. The Maintenance Director acknowledged awareness of the issue but stated repairs had not been completed due to other projects. The Administrator also acknowledged the wall was not repaired in a timely manner.
Failure to Investigate Allegations of Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of mental abuse for a resident with major depressive disorder and post-traumatic stress disorder, who was cognitively intact. The resident reported that staff had mocked and made fun of her delusions on several occasions, and stated that she had reported these incidents to someone in April, but no action was taken. The resident expressed that the mocking had a negative mental impact and made her reluctant to report further delusions. Social Services staff confirmed that the resident reported staff making fun of her, but because the resident did not want to file a grievance due to fear of retaliation, no progress note was made and the concerns were not escalated to facility administration for investigation. The administrator was unaware of the allegations and acknowledged that all reports of abuse should be investigated, regardless of whether a formal grievance was filed.
Failure to Complete Required PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II evaluation was completed for a resident admitted with diagnoses including schizoaffective disorder, bipolar type, and probable developmental delay. A PASARR Mental Health Evaluation conducted indicated the need for a Level II assessment for serious mental illness and intellectual or developmental disability. Despite this recommendation and supporting documentation from a hospital discharge summary, there was no evidence in the resident's medical record that a PASARR Level II for intellectual or developmental disability was completed. During interviews, both the Social Services Director and Social Services Coordinator acknowledged they did not request the required assessment and were unaware of when such a request should be made. The Administrator confirmed that the assessment was not completed as required.
Failure to Ensure Resident Access to Functional Hearing Aids
Penalty
Summary
A resident with a history of bipolar disorder was admitted to the facility and was documented as being able to hear adequately with the use of hearing aids. However, progress notes indicated that the resident's hearing aids were not working at the time of admission and subsequently became broken. Despite the resident's repeated reports to staff that the hearing aids did not work and did not fit properly, no effective action was taken to repair or replace them. Staff interviews confirmed that the hearing aids had not fit or worked since admission, and the resident had not worn them for about a week due to their condition. The hearing aids, along with unused batteries, were found stored in a cup at the resident's bedside, and no sound was coming from them. Social services staff were either unaware of the resident's need for hearing aids or acknowledged knowing about the issue but did not make efforts to address it. The Director of Nursing Services stated that staff were expected to report such issues so that social services could intervene, but she was unaware of the problem. As a result, the resident was left without functional hearing aids, requiring others to speak loudly and closely to be understood, which the resident found overstimulating. This lack of action led to the resident not having access to necessary hearing assistance devices.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with a history of pleural effusion, who had previously received physical therapy, was not offered restorative services to maintain or improve range of motion (ROM) after discharge from therapy. The resident expressed interest in continuing physical therapy or restorative services during a care conference, and a progress note indicated the resident would be a good fit for a restorative program. Despite this, there was no evidence in the clinical record that restorative services were provided. The resident reported not receiving physical therapy for over two months and not being offered ROM exercises, even though they wished to participate in restorative services. Staff interviews revealed confusion and lack of follow-through regarding the resident's enrollment in restorative services. One CNA believed the resident was receiving restorative care but had not observed participation, while another confirmed the resident was not on the restorative list. The restorative aide stated the resident was discussed for possible inclusion but was not added due to a full caseload. The RN case manager was unsure why the resident was not enrolled after expressing interest, and the regional administrator acknowledged the expectation that residents who express interest should be offered restorative services.
Failure to Follow Transmission-Based Precautions for Resident with C. diff
Penalty
Summary
Staff failed to consistently follow transmission-based precautions for a resident admitted with Clostridioides difficile (c-diff), who was on enteric precautions. Observations revealed that a CNA entered the resident's room without donning personal protective equipment (PPE) and subsequently exited the room, handled a lunch tray, and accessed common areas without performing hand hygiene. The CNA acknowledged awareness of the resident's precaution status but believed PPE was not required for meal delivery and admitted to not washing hands after leaving the room. Further observations showed another CNA provided care to the resident while wearing gloves but without a gown, and admitted to removing PPE before completing all care tasks. Additionally, the resident was observed ambulating in the hallway during a therapy session without PPE, despite being on transmission-based precautions and expected to remain in their room. Interviews with staff confirmed that education on precautions had been provided and signage was posted, but staff did not consistently adhere to the required protocols.
Failure to Properly Prepare Resident for Facility-Initiated Discharge
Penalty
Summary
The facility failed to properly orient and prepare a resident for a facility-initiated discharge, leading to a deficiency in safe discharge practices. Resident 11, who was admitted with diagnoses including depression, anxiety, alcohol abuse, and cannabis dependence, was provided with a list of assisted living facilities via email but was not given sufficient preparation or orientation for discharge. The resident left the facility for over 24 hours and was subsequently discharged against medical advice (AMA) without their medications. Staff 3, an RNCM, stated that the discharge was due to the resident's absence past midnight, while Staff 1, the Administrator, confirmed the discharge was facility-initiated and was unaware that an AMA discharge needed to be initiated by the resident.
Failure to Follow Diabetic Medication Orders
Penalty
Summary
The facility failed to adhere to physician's orders for a resident with diabetes, leading to a deficiency in diabetic medication management. The resident, who was admitted with diagnoses including diabetes, a fracture, and dementia, had specific orders for insulin administration. These orders included administering Humalog insulin based on a sliding scale for capillary blood glucose (CBG) levels, with instructions to notify the physician if CBG levels exceeded 351. However, the facility did not notify the physician on nine occasions when the resident's CBG levels were above this threshold. The deficiency was identified through interviews and record reviews, which revealed that staff members, including an LPN and an RNCM, acknowledged the failure to notify the physician as required. The resident's care plan and medical records indicated the need for close monitoring and communication with the physician, especially given the resident's moderate cognitive impairment and risk for complications from diabetes. Despite these requirements, the facility's inaction in notifying the physician as per the orders placed the resident at risk for unmanaged diabetes complications.
Facility Fails to Provide Palatable Food to Residents
Penalty
Summary
The facility failed to provide palatable food for four out of five sampled residents, which placed them at risk for unmet nutritional needs. The deficiency was identified through observations, interviews, and record reviews. Residents with various medical conditions, including severe protein-calorie malnutrition, Vitamin D deficiency, malnutrition, hepatic encephalopathy, hypertension, chronic kidney disease, and diabetes, reported dissatisfaction with the food quality. Test trays delivered to survey team members on two separate occasions were found to be unpalatable, with issues such as tough and dry chicken fried steak, salty ham, bland noodles, and overcooked carrots. Additionally, the food was not served at an appetizing temperature. Residents expressed their dissatisfaction with the meals, describing them as 'shitty,' tough, spicy, and lacking flavor. Complaints were also documented in Food Committee Meeting Notes, highlighting issues such as overly peppery seasoned potatoes, tough pork, cold and soggy fries, and consistently overcooked meat. Staff members, including the Administrator and DNS, sampled the test trays and confirmed the residents' complaints, noting the poor texture of the potatoes and the blandness of the noodles.
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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