Dallas Retirement Village Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Oregon.
- Location
- 377 Nw Jasper Street, Dallas, Oregon 97338
- CMS Provider Number
- 385207
- Inspections on file
- 26
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Dallas Retirement Village Health Center during CMS and state inspections, most recent first.
Staff failed to disinfect reusable lift equipment between resident uses and failed to perform hand hygiene while assisting multiple residents with meals. A CNA moved a mechanical lift and a ceiling-mounted lift between residents without cleaning them first, and during breakfast another CNA assisted two residents with food and a straw, touching a resident's face and returning to the first resident without sanitizing hands.
A resident with a stroke history and moderate cognitive impairment was hospitalized, but the record did not show that the resident or family received bed hold information. The family said no bed hold notice was provided, while staff reported that the policy was sent in a transfer packet and that follow-up to confirm receipt was not consistently done; the DON and admissions director gave differing accounts, and the administrator said bed hold information was mainly directed toward skilled residents.
A resident admitted with a nondisplaced R femur fracture did not have a baseline care plan completed within the required 48 hours of admission. Record review showed the plan was completed and reviewed after admission, and the RNCM stated baseline care plans were finalized within 72 hours, while the DNS acknowledged the plan was not completed timely.
A resident with depression and anxiety and a BIMS score indicating cognitive intactness had erythema under the neck fold that worsened in size and tenderness. An LPN documented notifying the provider, but there was no response in the provider notes, no follow-up documentation of additional calls, and no new treatment orders on the TAR.
Failure to follow a resident’s transfer care plan led to a fall. The resident had a dx of nondisplaced fx of the R femur, was dependent on staff for transfers, and was ordered to use a ceiling lift; the resident was also only to ambulate with therapy staff. Despite this, a CNA attempted to ambulate the resident with a FWW and gait belt during a transfer, and the resident lost balance and was guided to the ground. An RN later confirmed the care plan was not followed.
Failure to Assist Resident With Toileting Upon Request: A resident with chronic kidney disease, ADL self-care deficit, and mostly incontinent bowel/bladder status asked to use the bathroom, but a CNA told the resident incontinent care would wait until after lunch and left to pass meal trays. The resident attempted to stand and was later found in the bathroom. The DNS and Administrator stated residents should be assisted with toileting when requested.
The facility failed to properly clean glucometers, adhere to PPE protocols, and process laundry hygienically. Staff used alcohol wipes instead of EPA-registered wipes for glucometers, did not wear required PPE for residents on precautions, and left damp laundry overnight without rewashing. These actions increased the risk of infection spread among residents.
The facility failed to properly label and store medications, including an undated vial of tuberculin and incomplete temperature logs for medication refrigerators. Staff acknowledged these oversights, which did not meet the facility's expectations for medication management.
The facility was found to have sanitation deficiencies in food service and storage. A Dietary Aid handled a meal ticket that fell on the floor without changing gloves, and a communal refrigerator contained undated food items. Both the Dietary Aid and the Dietary Manager acknowledged the errors, and the Administrator confirmed the expectation for proper labeling.
A resident with severe cognitive impairment and post-traumatic hydrocephalus was physically abused by a CNA, as captured on video. The CNA was seen forcefully pushing the resident's legs and making a slapping motion towards the resident's face, causing distress. The facility's administrator and DNS confirmed the CNA's rough behavior, acknowledging it did not meet facility standards.
Failure to disinfect reusable equipment and perform hand hygiene between resident meal assistance
Penalty
Summary
The facility failed to disinfect reusable resident equipment between residents. On 4/6/26, Staff 7 used a mechanical lift to transfer a resident from one room and then took the lift to another room without cleaning and disinfecting it. The lift was later parked in the hallway without being cleaned, and Staff 7 stated that another staff member came through during the day and wiped off the lifts. The DNS later stated that mechanical lifts were reusable equipment and were to be disinfected between each resident. The facility also failed to ensure proper hand hygiene during meal assistance in the dining room. During a breakfast observation on 4/6/26, Staff 23 assisted Resident 35 with drinking from a straw, adjusted the straw with a hand, then assisted Resident 43 with eating yogurt and wiped the resident's mouth with a napkin without sanitizing hands, and then returned to Resident 35 to assist with eating eggs without sanitizing hands. Staff 23 stated he was not expected to sanitize his hands between residents unless he got up from the table, and the DNS stated staff were expected to perform hand hygiene between assisting residents with eating when food, straws, or the resident's face were touched.
Failure to Provide Bed Hold Information After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative was provided bed hold information when the resident was hospitalized. Resident 8 was admitted to the facility in 4/2025 with a diagnosis of stroke, and the 10/24/25 quarterly MDS indicated the resident was moderately cognitively impaired. Progress notes showed the resident was admitted to the hospital on 11/28/25, but the clinical record did not show that the resident or the resident’s representative received bed hold information. During interview, the resident’s family member stated that when the resident was admitted to the hospital in 11/2025, no bed hold information was provided. Staff stated that a transfer packet, including the bed hold policy, was sent with residents when they went to the hospital, and one staff member said she did not follow up to ensure the resident or representative received it. Another staff member stated the admissions director reviewed the bed hold policy with the resident or representative if a resident was admitted to the hospital, but the admissions director did not recall whether she followed up with Resident 8 or the family. The administrator stated residents on the long-term care unit were always allowed back to the facility and that bed hold information was more directed toward skilled residents.
Untimely Baseline Care Plan Completion
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident 59, who was admitted with a diagnosis of nondisplaced fracture of the right femur. Review of the resident’s baseline care plan showed it was completed and reviewed with the resident on 3/30/26, after the 3/27/26 admission date. The facility’s Baseline Care Plan policy dated 1/2026 stated that a baseline plan of care to meet the resident’s immediate needs shall be developed for each resident within 48 hours of admission. During interviews, Staff 20 (RNCM) stated baseline care plans for newly admitted residents were finalized within 72 hours of admission, and Staff 2 (DNS) acknowledged that Resident 59’s baseline care plan was not completed timely and needed to be finalized within 48 hours of admission.
Failure to Obtain Provider Orders for Worsening Skin Impairment
Penalty
Summary
The facility failed to obtain physician orders for treatment when Resident 80’s skin impairment under the neck fold worsened. Resident 80 was admitted with diagnoses including depression and anxiety, and the 10/2/25 Quarterly MDS indicated a BIMS score of 13, showing the resident was cognitively intact. A 10/22/25 physician order directed staff to monitor erythema under the neck fold every shift and notify the provider if the area deteriorated. On 12/3/25, Staff 8 documented that the erythema had increased in size and was tender to the touch, and noted that the provider was notified and staff were waiting for a response. However, provider progress notes on 12/3/25, 12/5/25, and 12/7/25 showed no response to the notification, and the resident’s progress notes contained no follow-up documentation of additional calls or provider direction. The 12/2025 TAR also showed no new treatments for the worsening erythema.
Failure to Follow Transfer Care Plan Led to Resident Fall
Penalty
Summary
The facility failed to implement appropriate transfer interventions to prevent falls for one resident who had been admitted with a diagnosis of nondisplaced fracture of the right femur. The resident’s care plan, initiated 3/30/26, directed nursing staff to use a ceiling lift for transfers, and a care plan initiated 4/1/26 stated the resident was only to ambulate with therapy staff. A 3/31/26 Functional Abilities Evaluation showed the resident was dependent on facility staff for transfers. Despite these directions, a 3/31/26 Incident Report documented a witnessed fall without injury in the resident’s room when a CNA attempted to ambulate the resident with a front wheel walker and gait belt. The CNA stated the resident lost balance during a transfer and was guided to the ground with low impact. A nursing progress note also stated the resident’s care plan directed staff to use a ceiling lift and that the resident was only to ambulate with therapy staff. The resident later stated the fall occurred during a standing transfer with nursing staff in the room, and an RN confirmed the resident’s care plan directed use of a ceiling lift and that the resident fell when the care plan was not followed.
Failure to Assist Resident With Toileting Upon Request
Penalty
Summary
The facility failed to ensure staff assisted a resident with toileting when requested. Resident 67 was readmitted to the facility in 4/2023 with a diagnosis of chronic kidney disease. The care plan revised on 4/2/26 identified the resident as having an ADL self-care deficit, being mostly incontinent of bowel and bladder, occasionally using a bedside commode for toileting, and requiring a mechanical lift for transfers. On 4/7/26 at 12:45 PM, Staff 15 entered the resident’s room and the resident stated he/she had to go to the bathroom. Staff 15 told the resident that he/she had an incontinent brief on and that incontinent care would be provided after lunch, then left the room to distribute other residents’ meal trays. The resident was observed attempting to stand, and when Staff 15 returned, the resident was located in the bathroom. Staff 15 later stated the resident did not always like to use the bedpan, was usually incontinent, and had not walked for at least three weeks. The DNS stated that if two staff were in the hall, one should assist residents with toileting upon request, and the Administrator stated a resident should be assisted with toileting when requested.
Infection Control Deficiencies in Glucometer Use, PPE Compliance, and Laundry Processing
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of community use blood glucose (CBG) glucometers between resident uses. Staff members were observed using alcohol wipes instead of the required EPA-registered wipes to disinfect the glucometers, contrary to the facility's policy and manufacturer instructions. This practice was noted among multiple staff members who used the glucometers for several residents, including a resident with diabetes, increasing the risk of bloodborne illness. The facility also did not adhere to transmission-based precautions for residents requiring enhanced barrier precautions and those on contact and droplet precautions. Staff members were observed not wearing the necessary personal protective equipment (PPE) such as isolation gowns when assisting a resident with lung cancer, who required enhanced barrier precautions. Additionally, staff failed to perform proper hand hygiene and PPE usage when handling food trays and entering isolation rooms for residents with COVID-19, including a resident with a recent positive test for COVID-19 and another with a diagnosis of clostridioides difficile. Furthermore, the facility's laundry processing practices were inadequate, as damp laundry was left in machines overnight and not rewashed before drying. This practice was confirmed by laundry staff and the Environmental Services Department Manager, who acknowledged that wet laundry was left in the washing machine overnight and transferred to the dryer the next morning without being rewashed, contrary to CDC guidelines for hygienically clean laundry.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. An open and undated vial of tuberculin was found in the nurses' station three medication room refrigerator, contrary to the manufacturer's instructions which require discarding the medication 30 days after opening. Staff 11, an LPN, acknowledged the vial was open and not labeled with an open date, and Staff 2, the DNS, confirmed that the expectation was for staff to label tuberculin with an open date. Additionally, the facility did not maintain accurate temperature logs for medication storage refrigerators. The temperature logs for the nurses' station one hall medication room refrigerator were blank from November 1 through November 25, and Staff 12, an LPN, acknowledged this oversight. Similarly, the temperature logs for the nurses' station two hall medication room refrigerator were blank on November 17 and November 29, with Staff 13, an RNCM, acknowledging the missing entries. Staff 2, the DNS, stated that the expectation was for the medication room refrigerator temperatures to be checked and logged twice daily, but acknowledged the lapses in documentation.
Sanitation Deficiencies in Food Service and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food service and storage, as observed in two separate incidents. In the first incident, a Dietary Aid was seen serving lunch in the second-floor kitchen when a meal ticket fell off the serving station onto the dining room floor. The Dietary Aid picked up the ticket with a gloved hand, returned it to the service station, and continued to handle service items without changing gloves. Both the Dietary Aid and the Dietary Manager acknowledged that the meal ticket should not have been placed back on the service station and that gloves should have been changed after touching the floor. In the second incident, a communal refrigerator in the facility's pantry area contained a clear container filled with meat covered in gravy and another container with leftover white cake, both without any date labels. The facility's Administrator stated that it was expected for food items to be dated and labeled with the resident's room number to which the item belonged.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident with severe cognitive impairment and post-traumatic hydrocephalus. The resident, who required substantial assistance with bed mobility and primarily spoke Spanish, was reportedly treated roughly and slapped by a CNA. The incident was captured on video footage, which showed the CNA forcefully pushing the resident's legs and making a slapping motion towards the resident's face, accompanied by audible distress from the resident. The video evidence was reviewed by the facility's administrator and director of nursing services (DNS), who confirmed the CNA's rough and aggressive behavior towards the resident. Despite the CNA's denial of the actions, the facility's staff identified the CNA in the video and acknowledged that the care provided did not meet the facility's standards and expectations. The resident expressed feeling unsafe in the facility, further highlighting the failure to protect the resident from abuse.
Latest citations in Oregon
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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