Cascade Terrace Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 5601 Se 122nd Avenue, Portland, Oregon 97236
- CMS Provider Number
- 385187
- Inspections on file
- 25
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cascade Terrace Post Acute during CMS and state inspections, most recent first.
Two residents with psychosocial risk factors reported that an RN made repeated undignified and unprofessional comments during intimate care, including telling them not to fart on him during peri and catheter care. Both residents described feeling uncomfortable, awkward, and disrespected. The RN acknowledged routinely using a phrase about not falling or farting on him with all residents as a supposed rapport-building joke, and another staff member confirmed hearing this comment during care. Facility leadership acknowledged that these comments did not honor resident dignity.
The facility failed to timely report an allegation of physical abuse to the State Agency after a resident with cognitive impairment was documented as placing a pillow over another resident’s face and throwing heat packs at the resident while sleeping. Nursing staff reported the incident to the Administrator, who decided it would be investigated internally but not reported externally, and other RNs confirmed that administration determined the event was not reportable. The Administrator acknowledged awareness that all abuse allegations must be reported within two hours but did not do so, resulting in a deficiency for failure to report suspected abuse.
A cognitively intact resident with type 2 DM and depression had a documented care plan specifying a preference for female caregivers to be present during care, including routine and skin assessments, to ensure comfort. Despite this, a male RN performed a skin assessment without a female caregiver in the room. An LPN and a CNA confirmed that the resident’s care plan and facility protocol required at least one female caregiver to be present during such assessments, and the administrator acknowledged that the RN failed to honor the resident’s stated needs and preferences.
A resident with obesity and diabetes did not receive prescribed weekly semaglutide injections on several occasions due to issues such as the medication not being filled, confusion about storage requirements, and unclear documentation. LPNs and the DNS confirmed the missed doses, with some staff unaware of proper medication storage procedures.
A resident with brain cancer received temozolomide chemotherapy for 23 days instead of the prescribed 5-day cycle due to a failure in order verification and documentation. This error led to severe blood cell deficiencies and required multiple transfusions and hospitalizations.
The facility did not ensure adequate supervision or hazard prevention for two residents—one with a history of substance use disorder who experienced fatal and non-fatal overdoses without appropriate care planning or staff training, and another with hemiplegia who was involved in a transfer-related fall without subsequent education or intervention for safe transfers.
The facility did not submit mandatory direct care staffing information for a fiscal quarter as required by policy, with both payroll/human resources staff and the administrator unaware of the omission and indicating that the corporate office was responsible for the submission.
The facility did not provide required training on its Quality Assurance and Performance Improvement (QAPI) program to staff. Multiple staff members, including CNAs and an LPN, reported they were unaware of the QAPI program and had not received any related training. Review of training records confirmed the absence of QAPI training for all staff.
The facility did not provide RN coverage for eight consecutive hours on four separate Saturdays, as required. Staff acknowledged the lack of RN coverage and noted challenges in staffing on weekends, while the administrator was unaware of these lapses.
The facility did not accurately post daily nurse staffing information, with errors including misclassification of staff roles and missing entries for Nursing Assistants on several days. Staff were incorrectly listed or omitted from the Direct Care Staff Daily Report, and administrative staff were unaware of these inaccuracies.
Surveyors found that medication carts containing prescription and over-the-counter drugs, including antibiotics and insulin, were left unlocked and unattended in hallways with staff and residents nearby. Additionally, expired medications and an opened vial of Tubersol without a documented open date were found in the medication storage room. Staff acknowledged these lapses in medication security and storage practices.
A resident with diabetes and an amputation, who was cognitively intact, did not receive requested double portions and a hamburger despite repeated requests and an order card specifying these preferences. Staff confirmed the resident's ongoing requests and noted inadequate systems for meeting food and cultural preferences.
Surveyors found that food items in unit refrigerators were not labeled or dated after opening, and personal employee beverages were stored alongside resident items. Additionally, the facility's only ice machine was not plumbed with an air gap, creating a risk of contamination for ice used in resident beverages. Staff acknowledged these practices did not meet facility expectations.
A resident with dementia and no documented cognitive impairment was found with Aspercreme lidocaine gel at the bedside, which the resident used independently. Staff confirmed that medications should not be kept at the bedside and that no assessment had been completed to determine the resident's ability to self-administer the medication.
Staff failed to maintain the privacy of resident health information by leaving an unlocked computer screen displaying sensitive data unattended and by leaving confidential paper records exposed on the nurses station counter. These actions resulted in multiple residents' personal and medical information being accessible to unauthorized individuals, with staff and administration acknowledging that such information should have been secured.
The facility did not complete comprehensive admission assessments within 14 days for three residents with complex medical conditions, including diabetes, chronic kidney disease, stroke, and amputation. Required MDS documentation and Care Area Assessments were incomplete or unsigned, and staff confirmed the assessments were overdue, resulting in a lack of timely information for individualized care planning.
Two residents had inaccurate MDS assessments: one was not coded as edentulous despite lacking natural teeth, and another was coded as having adequate hearing despite documented and observed hearing impairment. Staff confirmed the inaccuracies in both cases.
A resident with dementia and urinary retention, dependent on staff for bathing, did not receive scheduled showers as outlined in their care plan. Documentation and staff interviews confirmed that the resident did not refuse showers, yet bathing logs showed inconsistent provision of showers and a lack of documentation for missed or refused showers.
Two residents did not receive individualized activities in accordance with their documented preferences and care plans. Both were frequently left in their rooms without access to music, reading materials, or other preferred activities, and staff did not offer or facilitate these options, despite facility policy and care plan requirements.
Three residents did not receive care as ordered, including failure to obtain a custom AFO for a resident with hemiplegia, lack of assessment and treatment for a resident's pre-existing facial skin condition, and failure to administer PRN hydralazine for another resident with hypertension despite elevated blood pressure readings. Staff interviews confirmed that required actions were not taken in each case.
A resident with end-stage renal disease and severe cognitive impairment did not consistently receive required pre- and post-dialysis assessments or proper communication between the facility and the dialysis center. Documentation was missing for multiple dialysis sessions, and staff interviews confirmed that licensed nurses did not always complete necessary forms or assessments as outlined in facility policy.
A resident receiving Clopidogrel for clot prevention was not monitored for adverse side effects, despite developing multiple unexplained bruises. Staff interviews and record reviews confirmed that there was no documentation or orders for monitoring anticoagulant side effects, and expected shift documentation was not completed.
A resident with a stroke and cerebral edema, requiring extensive assistance, did not receive scheduled baths or showers as per their care plan. Despite being nonverbal and unable to refuse care, the resident's family noted the lack of bathing, and staff confirmed that showers were not completed due to low staffing levels. The facility's administration was informed but did not provide further information.
A resident with a PEG tube for nutrition was not administered tube feedings according to physician orders, with frequent delays documented. Staff confirmed that feedings should occur within an hour of scheduled times, but this was not consistently followed, risking insufficient nutrition.
Undignified Comments by RN During Intimate Care to Two Residents
Penalty
Summary
The deficiency involves staff failure to honor residents’ rights to be treated with respect and dignity during personal care. Resident 1, admitted with type 2 diabetes and depression, had a care plan dated 7/25/25 identifying risk for decreased psychosocial well-being and adjustment issues, with directions for staff to use appropriate and effective communication, encourage personal preferences, and honor quality-of-life choices to ensure dignity and respect. During a routine skin assessment on 2/6/26, Resident 1 reported that a registered nurse (Staff 6) stated, “don’t fart on me, a lot of people fart on me,” while examining the resident’s peri-area and areas near the anus. Resident 1 reported feeling disrespected, uncomfortable, and undignified, and stated the comment was unnecessary and did not want Staff 6 to provide care in the future. A CNA (Staff 7) corroborated hearing Staff 6 tell Resident 1 not to fart in his/her face during the skin assessment. Resident 5, admitted with cellulitis and agoraphobia, had a care plan dated 1/23/26 identifying risk to psychosocial well-being, including increased agitation and tearfulness, and directing staff to honor the resident’s preferences and choices to promote dignity and decrease anxiety. Resident 5 reported that the same RN (Staff 6) made unprofessional comments and “weird jokes” during care, including asking the resident not to fart on him while performing routine catheter care, which made the resident feel awkward and uncomfortable. In an interview, Staff 6 confirmed using the statement, “I am the registered nurse today. I have a couple of rules, don’t fall on me, don’t fart on me,” with all residents during care, explaining he believed it was humorous and a way to establish rapport. The Administrator (Staff 1) stated that Staff 6’s behavior and comments, including the phrase “don’t fart on me,” did not honor resident dignity and were inappropriate when providing resident care.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency within the required two hours after an incident involving two residents. Resident 9, who was admitted in 10/2024 with metabolic encephalopathy and atrial fibrillation and had a care plan dated 11/4/24 identifying cognitive loss affecting decision-making ability, was documented in a 2/7/26 facility incident report (completed on 2/15/26) as having placed a pillow over another resident’s face and thrown heat packs at that resident while the resident was sleeping. Staff interviews revealed that a RN case manager reported the incident to the Administrator, who stated the incident would be investigated but not reported to the State Agency, and the RN case manager believed administration handled the investigation. Another RN stated she reported the incident based on information from care staff, and that administration determined it was not reportable to the State Agency. The Administrator stated he was notified of the incident by care staff and did not report it to the State Agency because he did not believe it to be abuse, while acknowledging that all allegations of abuse must be reported to the State Agency within two hours of the allegation. This sequence of events, including the documented allegation of potentially abusive behavior by one resident toward another and the Administrator’s decision not to report the allegation despite staff notification and his awareness of reporting requirements, led to the deficiency for failure to timely report suspected abuse to the proper authorities.
Failure to Honor Resident’s Care Plan for Female Caregiver Preference During Nursing Assessment
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s care plan regarding caregiver gender preference during the provision of nursing care. The resident, admitted in July 2025 with diagnoses including type 2 diabetes and depression, had a 7/7/25 cognitive assessment showing a BIMS score of 15/15, indicating no cognitive impairment. The resident’s 7/25/25 care plan documented an individualized preference for female caregivers to promote comfort during care, and directed staff to ensure female caregivers were available when providing care. During a routine skin assessment on 2/17/26 at 10:19 AM, the resident reported that Staff 6 (RN), a male nurse, conducted the assessment without an additional female caregiver present in the room, contrary to the resident’s stated preference and the care plan directives. Interviews with staff confirmed awareness of the resident’s care plan and the expectation to honor the resident’s preference. On 2/17/26 at 11:07 AM, Staff 5 (LPN) stated that standard protocol based on the resident’s care plan was to ensure at least one female caregiver was present during routine assessments, including skin assessments, and acknowledged that staff were expected to honor this preference. At 11:15 AM, Staff 6 (RN) acknowledged providing care to the resident but refused to answer whether a female caregiver was present. At 12:04 PM, Staff 8 (CNA) stated that the resident’s preference was for female caregivers only and reported that Staff 6 provided nursing services without a female caregiver in the room. At 3:26 PM, Staff 1 (Administrator) stated that Staff 6 failed to honor the resident’s needs and preferences by performing nursing services without ensuring female caregivers were present.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for semaglutide (Ozempic) injections were followed for a resident with obesity and diabetes. The resident was admitted in 2025 and had a physician order dated 9/23/25 for weekly semaglutide injections. However, medication administration records and treatment administration records for October, November, and December 2025 showed that the resident did not receive the medication on multiple scheduled dates. Progress notes indicated that the medication was not administered due to reasons such as the prescription not being filled, a new order being needed, the prescription having ended, or the resident requesting a prescription, with some notes left blank. Staff interviews confirmed that the medication was not given as ordered, with one LPN stating she did not administer the medication because she believed it needed refrigeration and was unaware it was kept in the medication cart once opened. The Director of Nursing Services acknowledged the missed doses.
Chemotherapy Medication Administered in Excess of Prescribed Duration
Penalty
Summary
The facility failed to ensure that chemotherapy medications were administered as ordered for a resident with a diagnosis of Glioblastoma. The resident was supposed to receive temozolomide, a chemotherapy drug, for five days as part of a 28-day maintenance cycle, in accordance with standard dosing schedules and the prescriber's intent. However, due to a lack of clear documentation and order verification, the medication was administered daily for 23 consecutive days, far exceeding the prescribed duration. The error originated when a nurse transcribed the temozolomide order into the resident's clinical record without confirming the exact duration of administration, despite having a conversation with the neuro-oncology clinic. The nurse could not recall the specific instructions regarding the number of days the medication was to be given and relied on a paper order that was never located during the subsequent investigation. The Director of Nursing did not verify the entry or the existence of a valid paper order, and the medication was administered according to the incorrect transcription. The facility's policy required clarification of ambiguous orders and documentation of such clarifications, but this process was not followed. As a result of the prolonged administration of temozolomide, the resident developed severe complications, including thrombocytopenia, pancytopenia, and neutropenia, which necessitated multiple blood transfusions, emergency department visits, and hospitalizations. Interviews with facility staff and the resident's medical providers confirmed that the medication was given for a much longer period than intended, directly leading to these adverse outcomes.
Failure to Prevent Hazards and Provide Adequate Supervision for Residents with SUD and Mobility Risks
Penalty
Summary
The facility failed to keep residents free from hazards and provide adequate supervision, particularly for residents with a known history of substance use disorder (SUD) and those at risk for accidents during transfers. One resident with a history of polysubstance use was admitted and later experienced two critical incidents: first, being found unresponsive in the facility's parking lot due to a suspected opioid overdose, and second, being found deceased in their bathroom with drug paraphernalia present. Despite these events, there was no evidence that the resident's care plan addressed their history of substance use, nor was there any indication that monitoring for opioid use was initiated after the resident returned from the hospital following the first overdose. Staff interviews revealed a lack of knowledge and training regarding SUD. Multiple staff members, including CNAs, LPNs, and housekeepers, reported not receiving education on identifying signs and symptoms of drug use, monitoring residents with SUD, or handling drug paraphernalia. The Social Services Director confirmed that training on SUD was only provided to licensed nursing staff and not to CNAs or other direct care staff. Additionally, the facility did not update care plans or implement monitoring for other residents with a history of SUD, as identified by the Social Services Director. In another case, a resident with hemiplegia and severe cognitive impairment required extensive assistance for car transfers and had a witnessed fall during a transfer with a family member. Although a physical therapy referral was made, neither the resident nor the family member received education or training on safe car transfers following the incident. Staff were unaware that the resident continued to go out with the family member after the fall, and no further interventions were implemented to address the risk of future accidents.
Removal Plan
- Review all residents' records to identify other residents with history of or active substance use disorder.
- Identify residents with active, suspected, or history of substance use and list them in a binder at the nursing stations. Place a sticker on the residents' name plates outside their rooms to alert staff of potential hazards associated with active substance use disorder.
- Offer substance use treatment services to residents identified with history of or active substance use disorder.
- Assess residents identified with history of or active substance use disorder upon return from independent offsite outing for suspected substance use.
- Generate an incident report and notify law enforcement if required for residents assessed upon return from independent offsite outing or identified as active substance use.
- Educate staff, including temporary or agency staff, on the location of the binder with residents identified with suspected or history of substance use disorder.
- In-service staff, including temporary or agency staff, on substance use disorder, signs of abuse related to drug use, actions to take if active use is suspected, reporting suspected drug paraphernalia, and facility policy on resident possession and use of illegal substances.
- Place residents identified with drug paraphernalia or signs/symptoms of active drug use on alert monitoring, notify MD, place POC task to alert CNA for increased monitoring for drug paraphernalia, notify law enforcement if required, generate an incident report, and complete resident assessment.
Failure to Submit Required Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit the required direct care staffing information for fiscal year 2024, quarter four, as mandated by their Reporting Direct Care Staffing Information (Payroll-Based Journal) policy. The policy requires that complete and accurate staffing data, based on payroll and other verifiable and auditable sources, be electronically reported to CMS for each fiscal quarter within 45 days after the quarter ends. Review of records showed that the data for the specified quarter was not submitted. During interviews, the staff member responsible for payroll and human resources was unaware of the missing submission and indicated that the corporate office was responsible for this task. The facility administrator was also unaware that the data had not been submitted.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. During interviews, multiple staff members, including certified nursing assistants and an LPN, reported being unaware of the QAPI program and confirmed they had not received any related training. A review of the facility's list of new hire and annual trainings by the Payroll/Human Resources staff and the administrator confirmed that QAPI training was not included. This deficiency was identified for the entire facility, as no staff had received the required QAPI training.
Failure to Ensure Required RN Coverage on Multiple Days
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours on four separate Saturdays within a 33-day review period, as evidenced by the Direct Care Staff Daily Reports (DCSDR). Specifically, there was no RN coverage for the required duration on 7/20/24, 8/3/24, 3/22/25, and 4/12/25. Staff responsible for payroll and human resources acknowledged the lack of RN coverage on these dates and cited difficulty in finding RN coverage on weekends. The facility administrator was not aware of the absence of RN coverage on the identified days. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information for 14 out of 34 days reviewed. Review of the Direct Care Staff Daily Report (DCSDR) revealed incorrect information on multiple dates, including the entry of a 'Sitter' with hours worked as part of the staff count, and the absence of entries for Nursing Assistants on certain shifts. On one occasion, a staff member was observed wearing a CNA badge but confirmed he was not a CNA, and was not listed correctly on the DCSDR. Payroll/Human Resources staff acknowledged that the Sitter was a CNA assigned to one-on-one duties and should have been included in the CNA count, but the DCSDR did not accurately reflect this information. Further interviews confirmed that the same staff member worked with residents on several dates and should have been counted as a Nursing Assistant, but was not. The Administrator was unaware of the incorrect information on the DCSDR. These inaccuracies resulted in incomplete and inaccurate staffing information being posted for residents and the public.
Unsecured Medication Storage and Expired Medications Identified
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended in hallways, with both staff and residents passing by. On several occasions, medication carts containing prescription medications, over-the-counter drugs, antibiotics such as ceftriaxone, and insulin were found unlocked near resident rooms. Staff members, including a CMA and RNs, were noted to leave the carts unattended and unlocked, despite the expectation that medication carts should be locked when not in use. These observations were confirmed through interviews with staff, who acknowledged the expectation for secure storage. Additionally, the medication storage room was found to contain expired medications, including Vitamin A, Complete Women 50+ multi-vitamin with minerals, and L-Argine. A vial of Tubersol, used for tuberculosis testing, was also found opened without a documented open date, despite the requirement that it is only good for 30 days after opening. Staff confirmed the presence of expired medications and the lack of an open date on the Tubersol vial.
Failure to Meet Resident Dietary Preferences and Portion Requests
Penalty
Summary
A resident with diabetes and a below-the-knee amputation, who was cognitively intact, reported not receiving enough food and specifically requested larger portions. Despite having an order card for double portions and a hamburger on the side, the resident was observed receiving small portions and no hamburger. Staff interviews confirmed that the resident had requested double portions and a hamburger regularly, and that there was not a good system in place to meet resident preferences and cultural preferences for food. The dining manager and dietary staff acknowledged the resident's requests, but the upgrade to double portions was not implemented until after the deficiency was observed.
Improper Food Storage and Ice Machine Plumbing Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of food items in refrigerators located behind two nurses stations. Specifically, multiple food items, including covered plastic ramekins of peanut butter, a coffee mug with clear liquid and ice, and containers of nutritional shakes, were found opened, unlabeled, and undated. Staff members acknowledged these items should have been labeled with the date they were opened to ensure proper tracking and timely disposal. Additionally, an employee's personal beverage was found stored in one of the unit refrigerators, contrary to facility expectations. Further, the facility's only ice machine was found to be improperly plumbed, with its drain pipe lacking an air gap and discharging directly through a wall to the outside garden area. This setup did not prevent potential backflow of contaminated matter into the ice machine. The Dietary Manager confirmed the ice from this machine was used for preparing residents' beverages, and the Administrator acknowledged the risk of contamination due to the current drainage system.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with dementia and no cognitive impairment documented on the most recent MDS was found to have Aspercreme lidocaine gel, a topical pain reliever, at their bedside within reach. The resident reported using the gel on their heels. Review of the health record showed that no assessment had been completed to determine the resident's ability to safely self-administer this medication. Multiple staff members, including CNAs and an LPN, confirmed the presence of the medication at the bedside and stated that medications should not be kept in resident rooms, but rather in medication carts. The regional clinical support staff also confirmed that no self-administration assessment had been performed and that the medication should not have been left in the resident's room.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of resident records for three residents. In one instance, an unlocked computer screen on a treatment cart in a hallway displayed a resident's photo, name, gender, date of birth, age, allergies, code status, attending physician, vital signs, and scheduled treatments. The responsible LPN acknowledged forgetting to lock the computer screen, and the administrator confirmed that screens are expected to be locked when unattended to protect resident information. Additionally, four sheets of resident records containing private information, such as room numbers, names, and details about care (including ostomy bag changes, brief changes, and catheter care), were left unattended on the counter at the central nurses station. Staff were observed leaving these records unsupervised while going in and out of resident rooms, and other residents were seen passing by the exposed information. The LPN on duty confirmed the records were left out from the previous shift and acknowledged that confidential information should not be left in the open. The administrator stated that private information should be under staff supervision or covered.
Failure to Complete Timely Comprehensive Admission Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments within the required 14-day timeframe for three residents. For one resident with type 2 diabetes mellitus and chronic kidney disease, the Admission MDS was found incomplete 17 days after admission, lacking provider signatures in key sections and missing completed Care Area Assessments (CAAs) for multiple triggered care areas, including functional abilities, urinary incontinence, nutritional status, pressure ulcers, and pain. Another resident with a history of stroke and type 2 diabetes had an Admission MDS that was still in progress and overdue by five days, as confirmed by facility staff. A third resident, admitted with type 2 diabetes mellitus and a below-the-knee amputation, also had an incomplete Admission MDS 18 days after admission, with unsigned and incomplete CAAs for several triggered care areas such as cognitive status, mood, nutritional status, pressure ulcers, and pain. Staff interviews confirmed that the facility had overdue admission assessments for these residents. The lack of timely and complete comprehensive assessments placed the residents at risk for unmet care needs, as the necessary information to guide individualized care planning was not available within the required timeframe.
Inaccurate MDS Coding for Dental and Hearing Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two residents in the areas of dental status and hearing. For one resident with a history of traumatic brain injury, the dental treatment record indicated the resident was fully edentulous, yet the annual MDS did not reflect this status. Direct observation confirmed the absence of natural teeth, and facility staff acknowledged the inaccuracy in the MDS coding for this resident. For another resident admitted with heart failure, the nursing admission evaluation documented poor hearing in both ears. However, the admission MDS indicated the resident's hearing was adequate. Observations showed that the resident could only hear when spoken to at close range and with increased volume, and the resident reported being unable to hear and needing hearing aids. Multiple staff members confirmed the need to speak loudly and closely for the resident to hear, and facility staff acknowledged the MDS was inaccurately coded regarding the resident's hearing status.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received showers as scheduled, resulting in a deficiency related to activities of daily living (ADLs). The resident, who was admitted with dementia and had a catheter due to urine retention and bowel incontinence, was care planned to receive bathing or showering twice weekly or per preference. Documentation showed that the resident was dependent on staff for bathing and did not refuse showers. However, bathing logs indicated that the resident did not consistently receive showers according to the scheduled days, with significant gaps between shower dates. Interviews with the resident and multiple staff members confirmed that the resident did not refuse showers and expected to receive them at least twice a week. Staff acknowledged that missed showers should be made up the next day and refusals should be documented, but there was no evidence in the progress notes that additional showering opportunities were provided when showers were missed or refused. The regional clinical support staff confirmed that the resident did not receive showers as scheduled and that missed or refused showers should have been documented.
Failure to Provide Person-Centered Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program for two of three sampled residents, resulting in unmet psychosocial and quality of life needs. For one resident with dementia, assessments and care plans indicated preferences for activities such as reading, listening to music, spending time outdoors, and participating in religious services. Despite these documented preferences, the resident was frequently observed alone in their room, either in bed or in a wheelchair, often yelling for help. There were no books, newspapers, magazines, music, or TV available in the room, and the resident was not observed participating in group or one-to-one activities. Staff interviews confirmed the absence of activity materials and a lack of engagement with the resident's stated interests, with staff unaware of or not providing the preferred activities. Another resident, admitted with necrotizing fasciitis, had an activity assessment and care plan indicating the importance of listening to music, keeping up with the news, and having reading materials. Observations revealed that this resident was also left in their room without music, TV, or other activity materials, and staff did not offer to assist with turning on the TV or music. The resident expressed not knowing what activities were available and indicated interest in listening to music, podcasts, or audiobooks, but these were not provided. Staff interviews further revealed a lack of awareness of the resident's preferences and a failure to offer or facilitate the use of available activity resources. The facility's own policy required activities to be based on comprehensive, resident-centered assessments and to reflect individual preferences, with documentation in the medical record. However, both direct observation and staff interviews demonstrated that these requirements were not met for the two residents, as their preferences were not honored and activity materials were not provided or facilitated, despite being documented in their care plans and assessments.
Failure to Provide Ordered Treatments, Skin Assessments, and PRN Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. One resident with hemiplegia was determined to require a custom Ankle Foot Orthosis (AFO) for stabilization and assistance with activities of daily living. Despite multiple clinical notes and evaluations indicating the need for a custom AFO, there was no evidence that the facility obtained the device. Staff interviews confirmed that no action had been taken to secure the orthosis, and the resident and family member both reported that the brace had not been received or used as ordered. Another resident was admitted with spastic hemiplegia and was found to have red blotches and bumps on both cheeks, which were present prior to admission and caused irritation. The facility's policy required identification, assessment, and documentation of skin impairments, as well as notification of the physician and obtaining treatment orders if needed. However, the skin condition was not assessed or documented by nursing staff, and no treatment was initiated. Staff interviews revealed that the skin issue was not reported or evaluated, and the required procedures for new skin impairments were not followed. A third resident with hypertension had a physician order for as-needed hydralazine to be administered for blood pressures greater than 160. Multiple blood pressure readings above this threshold were recorded, but there was no evidence in the medication administration record that the medication was given as ordered. Staff confirmed that the resident should have received the medication when indicated, but this did not occur.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease and severe cognitive impairment. According to the facility's policy, licensed nurses were required to complete pre-dialysis and post-dialysis communication forms, monitor the resident before and after dialysis, and ensure communication with the dialysis center. Record review showed that for multiple dialysis sessions, there was missing documentation, including absent pre-dialysis, post-dialysis, and dialysis center communication forms. There was also no evidence that nursing staff contacted the dialysis center to obtain reports for several treatment dates. Interviews with staff confirmed that the required forms were not consistently completed and that assessments by licensed nurses were sometimes missed upon the resident's return from dialysis. A private caregiver reported that only CNAs typically took vital signs after dialysis, and licensed nurses did not perform assessments as required. Staff acknowledged the importance of the communication forms and assessments, and confirmed the gaps in documentation and communication for the identified dates.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
A resident with a diagnosis of peripheral vascular disease was admitted to the facility and prescribed Clopidogrel Bisulfate, an anticoagulant, for clot prevention. The April 2025 Medication Administration Record (MAR) indicated the resident was to receive 75mg of the medication daily at bedtime. Despite the known side effects of Clopidogrel, such as collection of blood under the skin and deep, dark purple bruises, there was no evidence in the medical record that adverse side effects were being monitored. During an interview, the resident displayed multiple bruises on both arms and was unaware of their origin. Staff interviews revealed that skin checks were only completed weekly, and no bruising had been documented. Additionally, a new skin tear was noted by staff, but there was no documentation of bruising or monitoring for side effects related to the anticoagulant in the resident's chart. Further review and interviews with nursing staff and clinical leadership confirmed the absence of any orders or documentation for monitoring the resident for adverse effects of anticoagulant therapy. Staff acknowledged that monitoring for side effects should have been conducted and documented each shift, but this was not done. The lack of monitoring and documentation placed the resident at risk for medication complications associated with anticoagulant use.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required extensive assistance due to conditions including a stroke and cerebral edema. The resident was admitted in August 2024 and was nonverbal, unable to express understanding, and required total assistance for bathing. The care plan specified that the resident was to be bathed or showered twice a week. However, records from August 2024 indicated that no baths or showers were completed for the resident during that time. Interviews with staff and a complainant revealed that the resident's family members frequently visited and noted the lack of bathing, even washing the resident's hair themselves due to neglect. A CNA confirmed that the resident was scheduled for showers during the evening shift, but these were not carried out. Another former CNA mentioned that staffing levels were low during that period, contributing to the failure to provide the necessary care. The facility's administrator and director of nursing services were informed of these findings but did not provide additional information.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feeding according to physician orders for a resident who was admitted with diagnoses including stroke and cerebral edema. The resident was nonverbal, NPO, and received nutrition via a PEG tube. The physician's orders specified that the resident should receive 290 ml of a standard formula with fiber five times a day at specific times. However, the facility did not adhere to these orders, as the tube feedings were frequently administered late, sometimes by several hours, as documented in the MAR Audit Report. Witnesses, including a complainant and several staff members, confirmed the discrepancies in the administration times. The registered dietitian and other staff members acknowledged that tube feedings should be administered within an hour before or after the scheduled times, but this was not consistently done. The assistant director of nursing and other staff confirmed the audit results, indicating that the tube feedings were not administered within the time frames ordered by the physician, placing the resident at risk for insufficient nutrition.
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A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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