Cottage Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cottage Grove, Oregon.
- Location
- 515 Grant Street, Cottage Grove, Oregon 97424
- CMS Provider Number
- 385152
- Inspections on file
- 20
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cottage Grove Post Acute during CMS and state inspections, most recent first.
Two residents did not receive their prescribed pain medications due to the facility running out of stock and failing to reorder in a timely manner. One resident, on hospice care and with a history of chronic pain, missed multiple doses of morphine, developed opioid withdrawal symptoms, and required hospitalization. Another resident with chronic joint pain missed several doses of Lyrica, resulting in severe pain that was not relieved by non-pharmacological interventions. Staff interviews confirmed ongoing issues with medication reordering and communication with providers.
Several residents, including those with reduced mobility, kidney disease, Multiple Sclerosis, and schizoaffective disorder, did not have their required MDS assessments completed on time. The LPN MDS Coordinator reported being behind due to workload, resulting in overdue Annual, Quarterly, and Discharge MDS assessments. Facility leadership confirmed that timely completion of MDS assessments is the expected standard.
Surveyors found that the facility did not consistently provide palatable or appetizing meals, as evidenced by overcooked pasta, bland vegetables, and flavorless bread and meatballs. Two residents reported dissatisfaction with the food, describing it as bland, sometimes cold, and unappealing. The Dietary Manager and Administrator confirmed the issues after sampling the meal.
Staff failed to prevent a resident from handling PPE supplies without sanitization, allowed soiled items to be placed near clean water and ice supplies, and did not implement enhanced barrier precautions or proper signage for a resident with open wounds. Multiple staff provided wound care without PPE, and staff were unaware of required precautions due to inconsistent care plan updates.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the physician was not notified of the transfer. Review of records and staff interviews confirmed the lack of physician notification.
A resident with anxiety and reduced mobility reported missing six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required smoking materials to be stored in these boxes, but it was found that the keys could open multiple boxes and the drawer was not consistently locked. Staff confirmed the security issues, and the facility lacked adequate tracking and safeguarding of residents' property, resulting in the loss.
A resident with heart and kidney disease was transferred to the hospital for symptoms such as nausea, diarrhea, malaise, cold sweats, and dizziness, but the facility did not provide the receiving provider with the responsible practitioner's contact information, advance directive details, or medication information prior to transfer. The DNS could not produce documentation confirming this information was communicated.
A resident with heart and kidney disease was discharged from hospice, but staff did not complete the required Significant Change MDS assessment within the mandated timeframe. The LPN/MDS Coordinator did not discuss the change with the resident or perform the assessment, and the DNS confirmed the oversight.
A resident admitted with multiple sclerosis and a Stage 3 pressure ulcer did not have a baseline care plan addressing wound care needs completed within 48 hours of admission. Staff confirmed that a care plan should have been initiated upon admission, but review of records and interviews revealed this was not done.
Two residents did not receive care as ordered by their physicians, including missed weight monitoring for a resident with heart failure and missed doses of Austedo for a resident with schizoaffective disorder due to medication unavailability. Documentation was inconsistent, and staff did not always notify the PCP promptly when issues arose.
A resident's pain medication was misappropriated due to a failure in following the facility's policy on handling controlled substances. An LPN received a package of narcotics but did not verify its contents and left it unattended. Another LPN later discovered the medication was missing, and the facility acknowledged the policy was not followed.
The facility failed to store narcotic pain medications safely, as required by policy, leading to the misappropriation of a medication card containing oxycodone tablets. Narcotic medications were left unattended and visible behind the nursing station, contrary to the policy of storing them in locked compartments. Staff interviews confirmed the lapse in procedure, and the incident was reported to law enforcement.
Failure to Provide Timely Pain Medication Results in Unmanaged Pain and Hospitalization
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services, resulting in significant lapses in care. One resident, who was cognitively intact and had a history of heart and kidney disease, was admitted to hospice and had physician orders for scheduled and PRN morphine for pain and shortness of breath. The facility ran out of the resident's prescribed morphine, and staff did not reorder the medication in a timely manner. As a result, the resident went several days without receiving the narcotic pain medication, experienced unmanaged pain, and developed symptoms consistent with opioid withdrawal, including nausea, vomiting, diarrhea, cold sweats, and elevated blood pressure. The resident was ultimately transferred to the hospital for evaluation and treatment. Documentation confirmed that seven doses of morphine were missed due to the medication being unavailable or not administered, and staff interviews revealed ongoing issues with medication reordering processes and communication with the on-call provider. Another resident with polyosteoarthritis had a physician order for Lyrica twice daily for pain management. The facility ran out of Lyrica, and the resident did not receive the medication for several doses over multiple days. During this period, the resident's pain levels fluctuated from 0/10 to 10/10, and non-pharmacological interventions were attempted but were not effective. Staff acknowledged that there was no designated person responsible for reordering medications, leading to frequent medication shortages, especially over weekends. The resident reported experiencing constant pain and stated that running out of pain medication was a recurring issue. In both cases, the facility's failure to maintain adequate medication supplies and ensure timely reordering directly resulted in residents experiencing unmanaged pain and, in one case, opioid withdrawal and hospitalization. Staff interviews and documentation confirmed that the medication management system was ineffective, with lapses in communication and follow-through on medication orders.
Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for four out of eight sampled residents. For one resident with reduced mobility and muscle wasting, the Discharge Return Not Anticipated MDS assessment was overdue by nine days. The MDS Coordinator confirmed being behind on work due to a busy schedule, resulting in the late assessment. Another resident with kidney disease and heart failure had an Annual MDS assessment overdue by thirteen days, with the same explanation provided by the MDS Coordinator. Additionally, a resident with Multiple Sclerosis had a Quarterly MDS assessment completed three days late. Another resident with schizoaffective disorder had both an Annual MDS and a Quarterly MDS completed late, with the Annual MDS overdue by over two weeks and the Quarterly MDS overdue by several days. The MDS Coordinator acknowledged the delays in all cases, and facility leadership confirmed that the expectation was for MDS assessments to be completed on time.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food to residents, as evidenced by observations, interviews, and test tray sampling. During a lunch meal service, the spaghetti noodles were found to be mushy, soft, and overcooked, the herb green beans tasted metallic and bland, and the garlic bread stick was doughy with no garlic flavor. The meat sauce was described as flavorful, but the meatball lacked flavor. The Dietary Manager confirmed these findings after sampling the meal, noting the pasta was soft, the green beans lacked taste, and the bread stick may have softened while sitting in the steam table. The Administrator acknowledged that overcooked pasta should not be a regular occurrence and expected the menu items to have the appropriate flavors. Two residents expressed dissatisfaction with the food. One resident, with a diagnosis of quadriplegia, reported that the vegetables were overcooked and bland. Another resident, with a history of depression, stated the food was terrible, sometimes cold, and the meat was occasionally too tough. This resident also reported that the spaghetti and meatball served for lunch were bland and needed more seasoning. These findings were consistent with the test tray results and staff observations, indicating a failure to consistently provide palatable and appetizing meals as required.
Failure to Follow Infection Control Standards and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards in multiple instances. On one hall, a resident was observed handling various items in a PPE cart, including masks and a stethoscope, for several minutes without staff intervention or subsequent sanitization of the cart. Although a staff member was present during the incident, no immediate action was taken to prevent the resident from touching the items or to clean the cart afterward. Staff later acknowledged that this did not align with infection control protocols. Additionally, on the same hall, a water pitcher cart was found near a room under enhanced barrier precautions (EBP) with an uncovered ice scoop and a soiled cup placed next to clean items, such as gloves and straws. Staff admitted that it was difficult to prevent residents from placing dirty items on the cart and that the presence of soiled items was not in line with best practices. Furthermore, a resident with open wounds requiring daily and twice-daily wound care did not have appropriate EBP signage posted outside their room, and multiple staff members provided care without donning PPE. Staff involved were unaware of the need for precautions and confirmed that care plans and signage were not consistently updated.
Failure to Notify Physician of Resident Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician when the resident was discharged to the hospital. The resident, who had a history of heart disease and kidney disease, was admitted to the facility in October 2024. On June 8, 2025, the resident was sent to the hospital due to symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. A review of the clinical record showed no documentation that the physician was informed of the hospital transfer. Interviews with facility staff confirmed that the physician was not notified at the time of the resident's hospitalization.
Failure to Safeguard Resident Personal Property
Penalty
Summary
A resident with anxiety and reduced mobility, who was cognitively intact, reported the loss of six packs of cigarettes from a locked storage box at the nurses' station. Facility policy required residents to store smoking materials in these locked boxes, with residents keeping a key and staff assisting with access. However, it was observed that the keys distributed to residents could open multiple boxes, compromising the security of personal property. The resident expressed concerns about the effectiveness of the locks and declined to store cigarettes at the nurses' station due to this issue. Staff interviews and observations confirmed that the drawer containing the cigarette storage boxes was not consistently kept locked, and a master key capable of opening multiple boxes was accessible in the same drawer. The facility's process for tracking and safeguarding residents' smoking materials was insufficient, as evidenced by the missing cigarettes and the lack of evidence regarding their existence. These lapses in securing residents' property led to the deficiency cited in the report.
Failure to Communicate Required Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving health care institution or provider prior to the transfer of a resident to the hospital. Specifically, for a resident admitted with heart disease and kidney disease, there was no evidence in the clinical record that the facility provided the contact information of the practitioner responsible for the resident's care, advance directive information, or details regarding medications (including when last received) before the resident was sent to the hospital for symptoms including nausea, diarrhea, general malaise, cold sweats, and dizziness. During an interview, the Director of Nursing Services was unable to provide documentation confirming that this information was given to the hospital prior to the resident's transfer.
Failure to Complete Significant Change MDS Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment (SCSA) within the required 14 days after a significant change in condition for a resident who was discharged from hospice care. The resident, admitted with heart and kidney disease, was noted to be cognitively intact and on hospice as of the last quarterly MDS. Staff confirmed that the resident graduated from hospice, but the MDS Coordinator did not discuss this change with the resident or complete the required SCSA. The Director of Nursing also acknowledged that the SCSA was not completed following the resident's discharge from hospice.
Failure to Initiate Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with multiple sclerosis and a Stage 3 pressure ulcer, did not have a baseline care plan addressing wound care needs documented in the care plan review. Observations confirmed the presence of the pressure ulcer, and staff interviews acknowledged that a care plan focused on the wound should have been initiated upon admission but was not completed. Record review and staff statements confirmed the absence of a timely baseline care plan for the resident's pressure ulcer.
Failure to Follow Physician Orders and Ensure Medication Availability
Penalty
Summary
The facility failed to follow physician orders and ensure proper documentation for two residents with significant medical needs. One resident with hypertensive heart disease and heart failure had physician orders for regular weight monitoring, including daily and weekly weights, to support cardiac management. However, the resident's weight was only documented a fraction of the required times, with inconsistent use of codes such as 'NA' and 'code six' without clear definitions. Staff interviews confirmed that weights or refusals were not consistently documented as expected, and there was a lack of clarity regarding the documentation process. Another resident with schizoaffective disorder and drug-induced dyskinesia did not receive prescribed doses of Austedo on multiple occasions due to the medication being unavailable. Documentation showed that the pharmacy was contacted after several missed doses, and there were delays in notifying the primary care provider (PCP) about the missed medication. The resident reported feeling the effects of missing the medication, and staff acknowledged that medications should be ordered in advance to prevent running out, with prompt notification to the PCP when medications are unavailable.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to ensure the proper handling and documentation of controlled substances, leading to the misappropriation of a resident's pain medication. A resident, who was admitted with a leg fracture, was supposed to receive a card of oxycodone containing 14 tablets. The medication was delivered to the facility along with other narcotics, but it was not properly checked or secured. Staff 4, an LPN, received the package but did not verify its contents and left it unattended at the nursing station. Later, Staff 3, another LPN, discovered that the resident's medication was missing. Interviews revealed that Staff 4 did not maintain direct observation of the medication package from the time it arrived until it was discovered missing. Staff 3, who was on break when the medications were delivered, was not informed about the delivery and only noticed the package later. The facility's policy on ordering and receiving controlled medications was not followed, as acknowledged by Staff 1. The incident was reported to law enforcement, but the facility could not substantiate the misappropriation at the time of the investigation.
Improper Storage of Narcotic Medications
Penalty
Summary
The facility failed to store narcotic pain medications in a safe manner, which placed residents at risk for misappropriation of medications. The facility's Controlled Medication Storage policy required narcotic pain medication to be maintained in separately locked, permanently affixed compartments. However, on a specific date, narcotic medications were delivered to the facility and were not stored according to this policy. Instead, the medications were placed behind the nursing station, visible to anyone, and not under direct observation. This lapse in procedure led to the discovery that a medication card of 14 tablets of oxycodone for a resident was missing. Interviews with staff revealed that the narcotic medications were received by an LPN who did not check the contents of the package and left it unattended. Another LPN noticed the package sitting on a computer at the nurse's station after returning from a break. The facility acknowledged that the policy was not followed, leading to the improper storage of narcotic pain medications. The incident was reported, and law enforcement was notified, but the resident did not miss any doses of pain medication.
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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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