Green Valley Rehabilitation Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eugene, Oregon.
- Location
- 1735 Adkins Street, Eugene, Oregon 97401
- CMS Provider Number
- 385156
- Inspections on file
- 22
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Green Valley Rehabilitation Health Center during CMS and state inspections, most recent first.
The facility did not maintain required RN coverage for at least eight consecutive hours per day on multiple days, as shown by review of Direct Care Staff Daily Reports over several months. Staff reported that the RN manager was only recently added to the staffing report, and the Administrator stated that staff were expected to call off two hours before their shift to allow time to find coverage. When surveyors requested payroll records to verify RN presence on the identified days, no additional documentation was provided, resulting in a cited deficiency for inadequate RN staffing.
A resident with depression and intact cognition reported missing jewelry, an oximeter, and art supplies to staff and during a resident council meeting, where residents had raised concerns about missing items. A CNA stated the resident had reported missing earrings and an oximeter and that she informed the charge nurse, but did not assist with another grievance form because the resident had already completed one. The facility’s grievance log showed no entry for this resident, and the Director of Social Services and Recreation could not locate or recall any grievance related to the missing items, suggesting it may have been lost amid staff confusion. The Administrator stated he would have expected staff to complete and resolve such a grievance within five days, but this did not occur, indicating the grievance process was not followed or tracked as required.
The facility failed to report an incident of potential neglect involving an elopement to the State Survey Agency. A resident with anxiety and a cognitive communication deficit was found off premises near a busy street after their wander guard device was not functioning. An internal elopement investigation identified confusion and device failure as the root causes, but no Facility Reported Incident (FRI) was submitted. The former administrator reported she would not report an elopement because it was no longer on the FRI form, and the current administrator confirmed that no FRI was completed, despite the regional RN’s expectation that an FRI be submitted for such an alleged violation.
A resident with severe cognitive impairment and a history of wandering had a care plan and TAR requiring a Wander Guard on the wheelchair and shift-by-shift checks of its placement and function, along with diversional interventions. Surveyors found no documentation that staff performed these required Wander Guard checks. The resident subsequently eloped and was found confused and in a precarious position near a busy street, and staff reported the resident did not have a Wander Guard on the wheelchair at that time. Although 15-minute checks were ordered after the elopement, there was no documentation that these monitoring checks were completed, and the administrator confirmed that no monitoring sheets could be located.
A resident who required moderate assistance for transfers and was cognitively intact reported being told by a speech therapist to urinate in bed if staff were unavailable to help with toileting, rather than attempting to transfer alone. The resident felt degraded by this comment, and the speech therapist confirmed she would give such instructions to prevent unsafe transfers.
A resident with a hip fracture and chronic pain did not receive prescribed pain medications on multiple occasions due to pharmacy and reordering issues, resulting in unmanaged pain. After a change in wound care orders, staff failed to monitor the surgical wound, leading to infection and hospitalization. Staff interviews confirmed lapses in medication administration and wound monitoring.
The facility failed to provide adequate staffing, resulting in delayed care, missed showers, and late meals. Residents experienced long call light wait times, were left in soiled briefs, and received late meal trays. Staff reported being unable to complete care tasks due to high resident acuity and insufficient staffing levels.
A facility failed to adhere to physician's orders for a resident with respiratory failure and asthma, leading to the resident attending an appointment without necessary oxygen support. The resident was later observed receiving oxygen at four liters per minute without a documented order, highlighting a lapse in following prescribed respiratory care protocols.
A resident with a stroke and moderate decision-making impairment was injured when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing a toe injury. The CNA left the resident alone without a call light and did not report the incident, leading to the resident's mistreatment and injury.
A facility failed to supervise a resident with dysphagia during meals, leading to unsupervised eating. Another resident with dementia and a history of elopement left the facility unsupervised and was missing for nearly 24 hours. Additionally, a resident with a history of falls fell from an elevated bed, resulting in leg fractures, due to inadequate adherence to safety protocols.
A resident reported being served moldy food, prompting an investigation that revealed unsanitary conditions and improper food storage in the facility. The dietary service logs showed inadequate food temperatures, and the unit refrigerator was found with unlabeled sandwiches, a broken shelf, and a sticky, uncleanable wooden shelf. Despite some labeling improvements, the unsanitary conditions persisted.
The facility failed to obtain informed consent for psychotropic medications for four residents. A resident with a pulmonary embolism was prescribed sertraline and lorazepam without consent. Another resident with bipolar disorder received duloxetine without being informed of the risks and benefits. A third resident, readmitted for leg fracture repair, was prescribed haloperidol and Ativan without consent. Lastly, a resident admitted after a stroke was given Lexapro without consent. Staff acknowledged the oversight in obtaining informed consent.
The facility failed to address grievances raised by the Resident Council, leading to a deficiency. Despite a grievance policy requiring immediate action, issues such as poor CNA performance, delayed meals, and mishandling of personal items were not resolved. Frequent changes in administration and unclear grievance handling responsibilities contributed to the problem, with no follow-up or resolutions documented.
The facility failed to ensure the Activities Director was a qualified professional. The Activities Director, promoted in July 2024, lacked the necessary certification, which was confirmed by the Administrator. This placed residents at risk for unmet physical, mental, and psychosocial needs.
The facility failed to ensure that three residents understood the arbitration agreement they signed. Despite being cognitively intact, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process. The Admissions Coordinator claimed to explain the process and provide contact information for questions, but the residents' feedback indicated a communication failure.
The facility failed to maintain proper infection control practices, including improper use of PPE, unsanitized medical equipment, and deficiencies in the laundry area. Staff were observed not wearing masks in COVID-19 areas, and a glucometer was not sanitized between uses, risking infection spread. Equipment issues in the laundry room further compromised infection control.
The facility failed to ensure a clean and homelike environment for residents, with issues such as cluttered rooms, unclean bathrooms, unpainted wall patches, and broken window blinds. Staff acknowledged these deficiencies, indicating a lack of effective communication and maintenance reporting.
The facility failed to document and resolve grievances for three residents and one unit, leading to unresolved concerns about missing personal items, rude staff interactions, moldy food, and inadequate incontinence care. Despite residents being cognitively intact and reporting issues, grievances were not properly recorded or communicated, indicating a systemic failure in handling grievances.
The facility experienced significant staffing shortages, resulting in delayed care for residents. Multiple complaints and observations highlighted long call light wait times and unmet care needs, such as incontinence care and meal assistance. A resident with heart disease frequently waited for bowel and bladder care, causing frustration and stress. Staff confirmed the facility was consistently short-staffed, with high turnover and frequent call-offs exacerbating the issue.
The facility did not staff an RN for eight consecutive hours per day for seven days out of 93 reviewed, risking unmet assessment needs. This was identified through staff daily reports from April to September 2024. The administrator, DNS, and regional nurse acknowledged the issue but provided no further information.
The facility failed to post accurate staffing information for six consecutive days, omitting census documentation for various shifts. This placed residents at risk for incomplete staffing information. The Administrator, DNS, and Regional Nurse acknowledged the requirement for staff to document the census for each shift.
A facility failed to ensure a safe system for a resident's self-administration of medication, leading to an adverse reaction. A resident, admitted with heart disease and cognitively intact, was assessed to self-administer medications, but the specific medications were not identified. The resident mistakenly applied Desitin to a skin graft site, worsening its condition. Observations showed unsecured medications in the resident's room, contrary to facility policy. Staff acknowledged the oversight, highlighting a failure in medication management.
A resident with chronic kidney disease expressed a desire to formulate an advance directive with a friend's help. Despite this being noted during a care plan conference, there was no documented follow-up or communication from staff to assist the resident in this process. A social services staff member confirmed the request but lacked documentation of any assistance provided.
A resident with a stroke diagnosis suffered a toe injury when a CNA, frustrated by a reassignment, pushed the resident's shower chair, causing the toe to hit a door. The CNA left the resident alone without a call light and did not report the incident. The facility's investigation lacked interviews with involved parties.
The facility failed to notify the State Long-Term Care Ombudsman of hospitalizations for two residents, one with cancer and another with anxiety and a leg fracture. Both residents were transferred to the hospital without the required notifications, leaving them without access to an advocate. Staff interviews confirmed that medical records staff did not complete the necessary notifications.
The facility failed to provide a bed hold policy to two residents transferred to the hospital, risking their knowledge of the right to return. One resident with cancer and another with anxiety and a leg fracture were not given the policy, and staff were unsure of the procedure. The absence of documentation was confirmed by the facility's administration.
The facility failed to update care plans for three residents, leading to potential unmet needs. A resident with chronic pain had undocumented personal equipment, another with depression and paraplegia lacked specific anxiety interventions and personal care preferences, and a third resident's care plan did not include interventions for psychotropic medications. Staff acknowledged these oversights.
Two residents in the facility experienced a lack of meaningful activities, leading to potential isolation. One resident with dementia and depression was often bored and unable to go outside due to the discontinuation of their electric wheelchair. Another resident with depression and anxiety reported that staff did not inquire about their interest in activities like crocheting. Staffing challenges in the activities department and the absence of activities staff at care conferences contributed to these deficiencies.
A resident with depression and paraplegia required hearing services, specifically ear cleaning, as identified in a care plan conference. Despite this, staff acknowledged ongoing hearing issues and ear wax build-up, which were not addressed due to the Unit Manager's failure to obtain necessary physician orders.
A resident at risk for pressure ulcers developed a Stage 3 ulcer that was not assessed or treated in a timely manner. Despite being reported by a CNA, the ulcer was not comprehensively assessed until three days later, and treatment was delayed. The LPN did not stage the ulcer, citing scope of practice limitations, and the presence of an RN in the facility did not lead to timely intervention.
The facility failed to provide adequate respiratory care for three residents. A resident with chronic pain had an unused, dusty suction machine in their room, contrary to physician orders. Another resident with a pulmonary embolism did not receive documented oxygen therapy, and staff were unclear about the orders. A third resident with respiratory failure had a nebulizer improperly stored and without cleaning instructions. These deficiencies indicate a lack of adherence to physician orders and standards of practice.
A resident with a leg fracture and pain from orthopedic devices did not receive PRN pain medication as ordered, despite frequent requests. The resident, cognitively intact, reported activating the call light for pain relief, but staff did not respond promptly due to low staffing and high workload. The facility acknowledged the expectation to administer pain medications as ordered.
A facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease. The resident's care plan required monitoring for infection, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, these checks were not consistently documented, and the order for checking the thrill and bruit was discontinued. Staff acknowledged missing documentation and poor communication with the dialysis center.
A facility failed to administer a prescribed fentanyl patch to a resident with post-surgical leg fractures due to a lack of a valid prescription. The pharmacy did not receive the necessary prescription, and staff did not follow up adequately to resolve the issue, despite the medication being available in the automated dispensing system.
The facility failed to monitor two residents on psychotropic medications, risking unnecessary medication use. One resident with bipolar disorder was not monitored for side effects of duloxetine, while another on hospice care received Ativan PRN without a care plan or non-pharmacological interventions. Staff acknowledged the lack of documentation and monitoring systems.
The facility failed to notify the physician and family members of three residents regarding refusals and changes in condition. A resident refused a prescribed lidocaine patch multiple times without physician notification. Another resident's family was not informed when the resident was sent to the hospital for catheter reinsertion. A third resident experienced a significant drop in oxygen levels, yet the physician was not notified.
A resident with dementia, stroke, alcohol abuse, and seizures eloped from the facility, and the incident was not reported to the State Agency until three days later. Staff failed to inform the administration about the elopement in a timely manner.
A CMA in the facility falsified documentation by guessing a resident's blood pressure instead of measuring it before administering Baclofen, a muscle relaxant. The medication was to be withheld if the systolic blood pressure was below 100, but the CMA documented a reading of 100/68 and administered the drug, despite the actual reading being 89/65. This action was confirmed by an LPN after a CNA reported the discrepancy.
The facility failed to provide adequate grooming and bathing care for three residents, leading to unmet needs. A resident with chronic pain received fewer showers than scheduled, while another with depression and paraplegia was not consistently assisted with bathing and shaving. A third resident, post-stroke, experienced inadequate bathing care due to staffing issues and lack of follow-up on refusals.
A facility failed to provide adequate care for residents with bowel, bladder, and catheter needs. One resident experienced significant delays in receiving bowel and bladder care, leading to frustration and stress. Another resident with a suprapubic catheter was not properly monitored, resulting in the catheter slipping out during routine care. A third resident with an allergy to aloe suffered from inappropriate incontinent care due to staff using the wrong wipes, causing skin irritation. These deficiencies highlight issues with staffing, communication, and adherence to care plans.
A facility failed to arrange specialized physician appointments for a resident with chronic pain, as identified during a survey following a public complaint. The resident was supposed to receive referrals to neurology and cardiology and a bilateral ultrasound-guided glenohumeral injection, as per a physician order. However, a staff member from Social Services acknowledged that these appointments were not scheduled.
A significant medication error occurred when a CMA failed to obtain a resident's blood pressure before administering Baclofen, a muscle relaxant. The resident's blood pressure was below the threshold for medication administration, but the CMA guessed the reading based on the morning measurement, leading to the medication being given inappropriately. An LPN was alerted to the error by a CNA, prompting an investigation.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours per day, seven days per week, as required, on 21 of 78 reviewed days between August and November 2025. Review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 showed that on multiple specific dates in each of those months there was no RN documented as being on duty for the required eight-hour period. Staff interviews revealed that staff were only instructed to begin reporting the RN manager on the Direct Care Staff Daily Report starting 1/13/25, and the Administrator stated that staff were expected to call off work two hours before their shift to allow time to find coverage. Surveyors requested payroll documentation to verify RN work on the identified dates, but no additional documentation was provided, and the deficiency was cited as placing residents at risk for unmet assessment needs. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was based on staffing records, staff interviews, and the absence of corroborating payroll documentation for RN coverage on the listed dates.
Failure to Process and Track Resident Grievance for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly process and resolve a resident grievance related to missing personal property, as required by its Resident Rights Grievances Policy and Procedure. The policy, revised in 3/2023, assigns the grievance officer responsibility for overseeing the grievance process, receiving and tracking grievances through conclusion, leading investigations, maintaining confidentiality, and issuing written grievance decisions. It also requires staff to immediately report any grievance alleging misappropriation of resident property to the grievance officer, with reports to be made available within seven business days and a summary report of the investigation available to the resident. Despite these requirements, the facility’s grievance list for 7/2025 and 8/2025 contained no grievances for the resident in question. The resident, admitted in 2/2025 with a diagnosis including depression and documented as cognitively intact with a BIMS score of 15 on an 8/31/25 MDS, reported missing jewelry, an oximeter, and art supplies in 8/2025. The resident stated these missing items were reported both to staff and during a resident council meeting, and the 8/26/25 Resident Council minutes reflected that residents reported missing items from their rooms, with this resident in attendance. A CNA reported that the resident told her in 8/2025 about missing earrings and an oximeter and that she reported this to the charge nurse, but did not assist with another grievance form because the resident had completed one the day before. The Director of Social Services and Recreation stated he did not remember any grievances for this resident regarding missing items and that no grievances were found for the resident for 8/2025, suggesting the grievance may have been submitted but lost due to confusion among multiple staff. The Administrator stated he would have expected staff to complete a grievance and have it resolved within five days, which did not occur in this case.
Failure to Report Resident Elopement as a Facility-Reported Incident
Penalty
Summary
The facility failed to report an incident of potential neglect related to an elopement involving Resident 28 to the State Survey Agency. Resident 28, admitted in February 2025 with diagnoses including anxiety and a cognitive communication deficit affecting expressive and receptive language, was found on 3/6/25 at approximately 4:30 PM about a block away from the facility next to a busy street. An Elopement Investigation Report dated 3/7/25 documented that the root cause of the incident was the resident’s confusion and a non-functioning wander guard (electronic monitoring device). Despite this documented elopement event and investigation, there was no evidence that the incident was reported to the State Survey Agency. During interviews, the former Administrator (Staff 40) stated she could not remember if the elopement was reported and indicated she would not report an elopement because it was no longer listed on the Facility Reported Incident (FRI) form. The current Administrator (Staff 1) stated that, to his knowledge, no FRI was completed for the resident’s elopement, and the Regional RN (Staff 22) stated that if there was an alleged violation, it would be expected that an FRI be submitted for an elopement.
Failure to Monitor Wander Guard and Document Safety Checks for Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and ensure proper monitoring for a resident with severe cognitive impairment and a history of wandering. The resident was admitted with anxiety and a cognitive communication deficit, and an admission MDS documented a BIMs score of three, indicating severe cognitive impairment. A care plan dated 3/4/25 identified episodes of wandering and ordered a Wander Guard to be placed on the resident’s wheelchair, with interventions including checking the Wander Guard placement on every shift and using diversions such as activities, food, conversation, television, and books. A TAR initiated in 3/2025 instructed staff to check the Wander Guard placement on the left area of the wheelchair every shift. However, there was no documented evidence in the clinical record that staff were checking the Wander Guard to ensure it was functioning properly. On 3/6/25, an elopement occurred in which the resident was found approximately one block away from the facility next to a busy street. An Elopement Investigation Report identified the root cause as the resident’s confusion and a non-functioning Wander Guard. A former physical therapist assistant reported finding the resident very confused and in a precarious position near the busy street and stated that a CNA assisted in returning the resident to the facility. The CNA reported that the resident did not have a Wander Guard on the wheelchair at that time. Although the resident was placed on 15‑minute checks with a monitoring sign‑up sheet created, there was no documented evidence in the clinical record that staff conducted these 15‑minute checks following the elopement. The administrator confirmed that no 15‑minute monitoring sheets could be located and stated that it would be expected for staff to check Wander Guard placement and functionality.
Resident Instructed to Urinate in Bed Rather Than Transfer Independently
Penalty
Summary
A resident with a history of hip fracture and fibromyalgia, who was cognitively intact and required moderate staff assistance for transfers, reported being told by a speech therapist to urinate in bed if staff were not available to assist with toileting, rather than attempting to transfer independently. The resident described this comment as mortifying and degrading. The speech therapist stated she did not recall the specific resident but acknowledged that she instructs residents to follow safety recommendations and, if aware of unsafe transfer attempts, would advise urinating in bed rather than risking injury by transferring alone. The interim Director of Nursing Services did not recall the incident or the resident but stated that staff are expected to treat all residents with dignity and respect.
Failure to Administer Medications and Monitor Wound Care per Orders
Penalty
Summary
The facility failed to administer medications according to provider orders and did not properly monitor a surgical wound for a resident admitted with a hip fracture and fibromyalgia. Medication administration records showed that Tramadol was not given on several occasions due to the facility not obtaining the medication from the pharmacy, and Oxycodone supplies also ran out, requiring emergency orders. Progress notes and interviews confirmed that the resident experienced significant pain on days when medications were missed, and both the resident and a family member reported multiple instances of being without pain medication. Staff interviews revealed lapses in medication reordering and administration, with admissions that medications were sometimes missed or late due to ordering issues. Additionally, after a change in wound care orders to a honeycomb dressing, there were no instructions for ongoing wound monitoring, and staff did not implement further wound observations or treatments. The resident subsequently developed signs of infection, including fever, chills, and wound redness, and was sent to the emergency department for treatment. Staff interviews indicated that wound care monitoring was expected but not consistently performed, and multiple attempts to reach the wound care nurse were unsuccessful.
Inadequate Staffing Leads to Delayed Care and Missed Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed care, missed or late meals, and increased safety risks. Observations revealed call light wait times of up to 40 minutes, and grievances highlighted instances where residents were left in soiled briefs for extended periods, missed showers, and received late meal trays. The facility's staffing records showed consistent shortages of Certified Nursing Assistants (CNAs) across multiple months, contributing to these deficiencies. Residents and their families reported numerous issues related to inadequate staffing. Residents frequently experienced long wait times for call lights to be answered, leading to missed incontinence care and delayed meals. Some residents were found soaked in urine, and others missed showers or had to wait for assistance with meals. Family members also observed these issues, with some taking it upon themselves to provide basic care, such as changing soiled briefs and emptying urinals, due to the lack of staff response. Staff members corroborated these accounts, describing the staffing situation as inadequate for the high acuity level of residents. They reported being unable to complete care tasks, such as showers and personal hygiene, and having to perform two-person transfers alone. The facility's staffing coordinator admitted to not staffing based on residents' acuity or needs, further exacerbating the problem. This systemic issue led to a failure in providing timely and adequate care to residents, as evidenced by the numerous grievances and staff testimonies.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to follow physician's orders related to oxygen administration for a resident diagnosed with respiratory failure with hypoxia and asthma. The resident was initially admitted with an order for continuous oxygen at 2 liters per minute via nasal cannula, which was discontinued upon their transfer to the hospital. Upon readmission, the resident did not have an order for oxygen. On a specific date, a staff member confirmed that the resident attended an appointment without an oxygen tank, resulting in a pulse oxygen reading of 64%. Observations on subsequent dates revealed the resident using a nasal cannula with an oxygen concentrator set at four liters per minute, despite no documented order for this level of oxygen. Staff confirmed the resident was on continuous oxygen without an order, and the Director of Nursing Services was informed of the situation.
Resident Injured Due to Staff's Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, resulting in physical injury. The incident involved a resident who was admitted with a stroke and had moderate decision-making impairment due to aphasia. The resident communicated using yes or no questions and gestures. On the day of the incident, a CNA was reassigned from her usual duties to provide direct care to residents, which led to her becoming angry. In her frustration, she pushed the resident's shower chair hard out of the shower room, causing the resident's toe to hit the door, resulting in a lifted toenail and bleeding. The CNA left the resident alone in the room without a call light and did not report the incident to another CNA. Multiple staff members, including another CNA and unit managers, confirmed the sequence of events, noting that the CNA left the resident in a vulnerable state, with only a towel on and the water running. The DNS acknowledged that the CNA did not complete a proper hand-off or report before leaving the floor, which contributed to the resident's mistreatment and injury.
Inadequate Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision for Resident 55, who was diagnosed with dysphagia and dementia. Despite the care plan requiring supervision during meals, Resident 55 was repeatedly observed eating alone in the dining room and in their room without staff presence. This lack of supervision posed a significant risk to the resident's safety, particularly given their difficulty swallowing and cognitive impairments. Resident 93, who had a history of dementia, stroke, alcohol abuse, and seizures, was allowed to leave the facility without proper supervision or signing out, as required by the facility's elopement prevention guidelines. The resident was missing for nearly 24 hours, during which time they were found by law enforcement five miles away from the facility with a non-functioning power wheelchair. Staff interviews revealed a lack of concern and adherence to protocol, as the resident was known to leave the facility unsupervised, despite being cognitively and physically unable to do so safely. Resident 164, who had a history of falls and cognitive impairment, fell from an elevated bed, resulting in fractures to both legs. The resident's care plan included interventions to prevent falls, but the bed was consistently kept at a high position, contrary to standard care practices. Staff failed to ensure the bed was in a low position or to provide mats on the floor, contributing to the resident's fall. The incident highlighted a lack of adherence to safety protocols and inadequate risk assessment for the resident's known fall risks.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to serve food at appropriate temperatures and maintain sanitary conditions, which placed residents at risk for foodborne illnesses. One resident, who was cognitively intact and had a diagnosis of heart disease, reported being served moldy food. The former administrator confirmed that the resident called the police regarding the moldy food, and although the facility discarded perishable snacks, there was no verification of the food's condition. A Licensed Practical Nurse (LPN) saw photos of the food, which showed a sandwich with green mold and a fruit cup with white bumps, indicating the onset of mold. Additionally, the facility's dietary service logs recorded inadequate holding temperatures for chicken, poultry, and meatloaf, with no system in place to verify final cooking temperatures. The unit refrigerator was found in an unsanitary condition, with sandwiches lacking expiration labels, a broken shelf, and a sticky, uncleanable wooden shelf. The Infection Prevention Nurse confirmed the unsanitary conditions and the need for a cleanable surface shelf. Despite the addition of date labels on sandwiches, the overall condition of the refrigerator and surrounding area remained unchanged over five days.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide informed consent for the use of psychotropic medications to four out of five sampled residents. Resident 55, admitted with a pulmonary embolism, was prescribed sertraline and lorazepam without documentation of informed consent. Staff acknowledged a system issue related to providing risk and benefits information. Resident 87, diagnosed with bipolar disorder, received duloxetine without being informed of the risks and benefits, as confirmed by a Unit Manager. Resident 164, readmitted for surgical repair of leg fractures, was prescribed haloperidol and Ativan without obtaining consent, as social services staff were not present to obtain it. Resident 165, admitted after a stroke, was administered Lexapro without consent, with social services staff acknowledging the oversight. The lack of informed consent for these medications placed residents and their responsible parties at risk for lack of informed consent.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to provide a response to grievances raised by the Resident Council, which was identified as a deficiency. The grievance policy, revised in March 2023, required the grievance officer, typically the administrator, to take immediate action to prevent further potential violations of any resident rights while a grievance was investigated. However, the facility did not adhere to this policy. The Resident Council minutes from July and August 2024 documented several unresolved issues, including poor CNA performance, delayed meals, and mishandling of personal items. During a meeting in September 2024, residents expressed that their grievances were not addressed, and they received no follow-up, which affected their psychosocial well-being. The facility experienced frequent changes in administration, with three different administrators in the past year, leading to inconsistent communication and a lack of clarity regarding grievance handling responsibilities. Staff 7, the Activities Director, noted that grievances were given to department heads who were unaware of the proper procedures, resulting in a breakdown in the grievance process. The online grievance log lacked a follow-up section and did not specify who was responsible for addressing concerns. Staff 1 confirmed that there were no resolutions to the grievances, indicating a systemic failure in the facility's grievance handling process.
Unqualified Activities Director
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which was identified during an interview and record review. Staff 7, who was responsible for directing the activities program, including organizing the Resident Council, had been working in the activities department since May 2023 and was promoted to the Director position in July 2024. However, Staff 7 acknowledged that she did not have the required activities certification. This was confirmed by Staff 1, the Administrator, who admitted that the certification for Staff 7 was not completed as required. This deficiency placed residents at risk for unmet physical, mental, and psychosocial needs.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the meaning of an arbitration agreement, which involves resolving disputes with a neutral party rather than in court. This deficiency was identified for three residents who were cognitively intact at the time of signing the agreement. Resident 19, admitted with a fracture of the left femur and chronic kidney disease, stated they knew what arbitration meant but did not remember signing the agreement. Resident 163, admitted with kidney and respiratory failure, remembered signing the agreement but their spouse had questions about the process and felt pressured to sign. Resident 262, admitted with respiratory failure and gout, did not remember signing the agreement and stated that arbitration was not explained during admission. Staff 59, the Admissions Coordinator, stated that she informed all new admissions of their right to decline or agree to arbitration and that they had 30 days to change their mind. She claimed to explain the definition and process of arbitration and offered a copy of the agreement to all admissions, providing her business card for any questions. Despite these claims, the residents and their representatives reported a lack of understanding and felt uninformed about the arbitration process, indicating a failure in communication and ensuring informed consent.
Infection Control Deficiencies in PPE Use and Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices across multiple areas, including the use of personal protective equipment (PPE) and the handling of medical equipment. Observations revealed that staff members were not consistently wearing masks, particularly in areas with active COVID-19 cases. Additionally, PPE storage bins outside COVID-19 positive rooms were missing supplies, and staff were not wearing proper eye protection in these areas. The breakfast cart was observed with an uncovered tray, which was delivered to a resident's room, contrary to infection control protocols. Furthermore, the community use CBG glucometer was not sanitized between uses, posing a risk of bloodborne illness transmission. The laundry area also exhibited significant deficiencies, including a fan blowing from the dirty to the clean side, visible dirt on the fan, and inadequate air circulation. Equipment issues were noted, such as a leaking washing machine, a broken dryer heating element, and a washing machine with a broken door. These issues were acknowledged by staff, who indicated that repairs had been attempted multiple times without permanent resolution. Resident 20, who was cognitively intact and had a history of diabetes and infection, was directly affected by the improper sanitization of the CBG glucometer, as observed during a blood sugar check.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple deficiencies observed in the rooms of five residents. Resident 2's room was cluttered with various items, including an arctic air conditioner covered in thick dust, which had not been cleaned for three years despite the resident's requests for assistance. Resident 62's bathroom was found to be unclean, with urine and dark brown debris around the toilet bowl and yellow-colored debris on the floor, despite housekeeping efforts. Staff acknowledged these conditions, confirming the lack of a homelike environment. Additional deficiencies were noted in the rooms of Residents 98, 71, and 162. Resident 98's room had an unpainted wall patch that had been present since their move-in, and Resident 71 confirmed the patch was there during their stay. Resident 162 reported a broken window blind control wand, which was not recorded in the maintenance log, preventing the adjustment of blinds to let sunlight into the room. Maintenance staff confirmed the missing wand and acknowledged the dependency on nursing staff to report such issues, highlighting a communication gap in addressing maintenance concerns.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, as evidenced by the lack of documentation and resolution of grievances for three residents and one unit. Resident 63, who was cognitively intact, reported a missing ring, but there was no grievance documentation or progress notes regarding the incident, despite the administrator's acknowledgment of the issue. Resident 98, also cognitively intact, reported rude treatment by staff and delays in care, but no grievance form was completed, and the administrator was unaware of the concern. Additionally, Resident 162, who was cognitively intact, reported moldy food and called the police, but there was no grievance form related to the issue, and the current administrator was not aware of the incident. Furthermore, a public complaint was received about untimely incontinence care and an unplugged call light, but only one grievance was documented for the month. Witness 4 reported multiple residents with unmet care needs, including missing blankets and skin breakdown due to lack of incontinence care, but these concerns were not documented in the grievance log. Staff 33 and the unit managers acknowledged the issues, but the grievances were not properly recorded or communicated to the administration, indicating a systemic failure in the facility's grievance handling process.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by multiple complaints and observations of long call light wait times and unmet care needs. Residents reported waiting excessively for assistance, with some experiencing incontinence due to delays. Staff interviews confirmed that the facility was consistently short-staffed, leading to delays in care and incomplete tasks such as showers and meal assistance. Resident 24, who was cognitively intact and admitted with a diagnosis of heart disease, frequently experienced delays in receiving bowel and bladder care. On one occasion, the resident activated the call light for assistance, but staff did not respond promptly, resulting in the resident waiting with a soiled brief. This delay caused significant frustration and emotional stress for the resident, who also reported that staff did not wake them for meals, leading to cold food being left uneaten. Staff members expressed frustration with the staffing challenges, noting that they were unable to provide the necessary care to residents. The facility experienced high staff turnover and frequent call-offs, exacerbating the staffing shortages. Observations and interviews revealed that call light wait times often exceeded 30 minutes, with some instances reaching up to 99 minutes. The facility also faced challenges during outbreaks of norovirus and COVID-19, which further strained staffing resources.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for seven out of 93 days reviewed. This deficiency was identified through a review of the Direct Care Staff Daily Reports covering specific periods from April to September 2024. The reports revealed that on seven days, there was no RN coverage for eight consecutive hours on any shift within a 24-hour period. This lack of consistent RN coverage placed residents at risk for unmet assessment needs. During interviews on September 13, 2024, the facility's administrator, director of nursing services (DNS), and regional nurse acknowledged the issue but did not provide additional information regarding the required RN coverage.
Failure to Document Census in Staffing Reports
Penalty
Summary
The facility failed to post accurate and complete staffing information for six consecutive days, which placed residents at risk for incomplete and inaccurate staffing information. On multiple occasions, the Direct Care Staff Daily Report lacked documentation of the census for various shifts. Specifically, on September 8th, no census was documented for the day and evening shifts, and the night shift posting was incomplete. Similar omissions occurred on September 9th, 10th, 11th, 12th, and 13th, with the day shift census missing on each of these days. During an interview on September 13th, the Administrator, Director of Nursing Services, and Regional Nurse acknowledged that staff should document the census for each shift on the report.
Failure in Safe Medication Self-Administration System
Penalty
Summary
The facility failed to ensure a safe system for a resident's self-administration of medication, which placed residents at risk for adverse medication reactions. Resident 44, who was admitted in 2021 with a diagnosis of heart disease and was cognitively intact, was assessed on a Self-Administration of Medication form to be capable of self-administering medications. However, the form did not specify which medications the resident could self-administer. The resident's care plan indicated that they self-administered over-the-counter supplements kept at their bedside, but it also failed to identify specific medications for self-administration. An incident occurred where Resident 44 mistakenly applied Desitin to an old skin graft donor site, which worsened the condition of the site. Observations revealed that the resident's room contained multiple bottles of supplements, creams, and liquid disinfectants, including a tube of Desitin, which were not secured as required. Staff acknowledged that medications were supposed to be locked in a secure area and that the resident had orders for only two supplements to be kept at the bedside. This oversight in medication management and storage led to the resident's adverse reaction and highlighted the facility's failure to maintain a safe self-administration system.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist a resident with formulating an advance directive, which is a deficiency in honoring residents' rights to make end-of-life choices. The resident, admitted in 2022 with chronic kidney disease, was cognitively impaired but able to express needs and desired to create an advance directive with the help of a friend. During an IDT Care Plan Conference, this wish was noted, but from the period of late July to early September, there was no documentation of follow-up or communication with the resident or their friend regarding the advance directive. A staff member from Social Services acknowledged the resident's request but could not provide any documentation of assistance being offered or completed.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury involving a resident who was admitted with a diagnosis of stroke. On the day of the incident, a CNA was responsible for showering the resident and accidentally bumped the resident's foot against the wall while exiting the shower room. The CNA left the facility before the end of her shift, leaving the resident sitting in the shower chair. Another CNA later found the resident's toe bleeding, with no prior report or communication about the incident. The facility's investigation, conducted by a Unit Manager-LPN, did not include interviews with the resident, other CNAs, or nurses involved. A staff member reported that the CNA became angry due to a reassignment and pushed the resident's shower chair hard, causing the resident's toe to hit the door, resulting in a lifted toenail and significant bleeding. The CNA left the resident alone in the room without a call light and did not inform another CNA of her departure.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization of two residents, which is a requirement to ensure residents have access to an advocate who can inform them of their options and rights. Resident 95, who was admitted with a diagnosis of cancer, requested to be sent to the hospital for shortness of breath. Emergency services were called, and the resident was transferred to the hospital. However, there was no documentation in the resident's clinical record indicating that the State Long-Term Care Ombudsman was notified of this transfer. Similarly, Resident 262, admitted with diagnoses including anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure after experiencing severe pain. Despite being cognitively intact, as indicated by a BIMS score of 15, there was no documentation of a transfer notice with appeal rights being provided to the resident or notification to the Ombudsman. Staff interviews revealed that the medical records staff, who were responsible for sending discharge information to the Ombudsman, did not complete these notifications.
Failure to Provide Bed Hold Policy to Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold policy to two residents who were transferred to the hospital, which is a requirement to ensure residents are informed of their right to return to the facility. Resident 95, who was admitted with a diagnosis of cancer, was transferred to the hospital for shortness of breath. There was no documentation in Resident 95's clinical record indicating that a bed hold policy was provided at the time of discharge. Staff members, including those from social services and admissions, were unsure of who was responsible for providing the bed hold policy, and it was confirmed that the policy was not present in the resident's record. Similarly, Resident 262, admitted with anxiety and a leg fracture, was transferred to the hospital for a disimpaction procedure. The resident's clinical records lacked documentation of a bed hold policy being provided in writing at the time of transfer. The resident, who was cognitively intact, stated they were unaware of the bed hold policy. The facility's administrator and director of nursing services confirmed that no bed hold notice was given to Resident 262 upon transfer to the hospital.
Failure to Revise Care Plans for Personal Equipment and Medications
Penalty
Summary
The facility failed to revise care plans for three residents, leading to potential unmet needs. Resident 2, admitted in May 2016 with chronic pain, had a mini arctic air conditioner and a suction machine in their room, but these were not documented in the care plan as of July 2024. This oversight was acknowledged by the Unit Manager-LPN during an observation in September 2024. Resident 86, admitted in March 2024 with depression and paraplegia, had a care plan revised in June 2024 that lacked specific interventions for anxiety and personal preferences for dressing and shaving. Staff noted the resident required encouragement to accept care due to anxiety, and the resident expressed a preference for being clean-shaven and choosing clothes when leaving the facility. The absence of these details in the care plan was confirmed by the Social Services staff. Additionally, Resident 165, readmitted in August 2024 post-surgery, had a care plan from 2022 that did not include interventions for the use of haloperidol and Ativan, nor monitoring for adverse reactions or triggers for anxiety. The LPN Resident Care Manager acknowledged that the care plan was not updated.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for two residents, leading to a lack of social interaction and potential isolation. Resident 14, who has dementia and depression, expressed a desire to engage in favorite activities and go outside. However, observations revealed that the resident often sat in the hallway with nothing to do and was bored. The resident's care plan was not updated to reflect the discontinuation of their electric wheelchair, which limited their ability to go outside independently. Additionally, the activities staff did not attend care conferences, resulting in a lack of support for the resident's activity needs. Resident 54, diagnosed with depression and anxiety, also experienced a lack of engagement in activities. Despite expressing interest in activities such as crocheting, the resident reported that staff did not inquire about their interests. The activities department faced staffing challenges, which contributed to incomplete assessments and a failure to capture important information about residents' preferences. The absence of activities staff at care conferences further hindered the facility's ability to meet the residents' needs.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to follow through on necessary hearing services for a resident, leading to a deficiency in maintaining adequate hearing. The resident, admitted in March 2024 with diagnoses including depression and paraplegia, was identified during a care plan conference in May 2024 as requiring hearing services, specifically ear cleaning. Despite this, a quarterly assessment at the end of May indicated the resident had no hearing aids and adequate hearing. However, by September, staff acknowledged the resident had hearing issues and ongoing ear wax build-up, which was supposed to be addressed through physician orders. The Unit Manager confirmed that she neglected to obtain the necessary physician orders for ear wax removal, resulting in a lack of follow-through on the required services.
Delayed Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a pressure ulcer for a resident who was admitted with no pressure ulcers but was at risk due to incontinence and required assistance for repositioning. On a specific date, a CNA reported an open area on the resident's coccyx, but no comprehensive assessment was conducted until three days later. The wound was identified as a Stage 3 pressure ulcer with significant slough, and it was determined to be facility-acquired. Treatment was not documented as completed until four days after the initial report. The delay in assessment and treatment was partly due to the LPN's understanding that staging a pressure ulcer was outside their scope of practice, and the absence of a comprehensive assessment by an RN, despite one being present in the building. The facility's staff acknowledged the delay in staging and measuring the ulcer, which should have been done when the pressure ulcer was first identified.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services according to physician orders and standards of practice for three residents. Resident 2, admitted with chronic pain, had a suction machine in their room that was covered in dust and had not been used for years, despite a physician order to check and replace the canister weekly. The unit manager acknowledged the oversight and confirmed the machine should have been removed as it was not in use. Resident 55, admitted with a pulmonary embolism, had orders for oxygen therapy to maintain oxygen saturation levels above 90 percent. However, from the beginning of September, there was no documentation of oxygen administration, and observations confirmed the resident was not receiving oxygen. The facility staff were unsure if the orders were PRN, and the hospice medication list provided was not a signed physician's order. Resident 87, with respiratory failure and congestive heart failure, was to receive inhalation medication but had their nebulizer improperly stored and without clear instructions for cleaning and maintenance. The unit manager acknowledged the need for proper cleaning and storage instructions.
Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medications as ordered for a resident admitted with a leg fracture and pain due to internal orthopedic prosthetic devices. The resident, who was cognitively intact with a BIMS score of 15, experienced frequent pain affecting sleep quality and daily activities, with pain levels reaching up to 10 on a scale of zero to 10. The medication administration record (MAR) for September instructed staff to administer oxycodone 5 mg every four hours PRN for moderate pain, with specific dosages based on pain levels. On September 7, the resident was administered 10 mg of oxycodone at 1:07 AM, 5:14 AM, and 12:11 PM for pain levels of eight and 10. However, the resident reported activating the call light at 9:15 AM on September 7 to request PRN pain medication, but no staff responded until 12:00 PM when lunch was delivered. Staff interviews revealed that the resident was consistent in requesting PRN pain medications, but due to low staffing levels and high workload, the medication was not administered as needed. Staff 46, who was responsible for administering the medication, stated that she might not have been informed of the resident's request and was assigned to both units, which may have prevented her from administering the medication. The facility's administration confirmed the expectation to provide pain medications as ordered by the physician and to follow through with PRN requests.
Failure to Provide Proper Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care and services for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who was cognitively intact, reported that staff did not check her/his fistula or vitals upon return from dialysis sessions. The resident's care plan required monitoring for infection at the fistula site, bleeding, and symptoms of kidney malfunction, as well as checking the thrill and bruit of the fistula. However, the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from June to September 2024 did not include orders for these necessary checks, and the order to check the thrill and bruit was discontinued in June 2024. The resident had 45 opportunities to attend dialysis sessions between June and September 2024, but the facility completed pre-dialysis paperwork only 35 times and post-dialysis paperwork just four times. Staff interviews revealed that the pre-dialysis forms were sometimes lost, and there was poor communication with the dialysis center. The Unit Manager acknowledged the missing documentation and the lack of an order for checking the thrill and bruit, indicating a failure to adhere to the care plan and ensure proper post-dialysis monitoring.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to obtain a resident's medication, specifically a fentanyl patch, for a resident who was readmitted with a diagnosis of post-surgical repair of leg fractures. The medication administration record (MAR) indicated that the fentanyl patch was to be applied starting on 9/9/24, but it was not applied. A pharmacy technician stated that the pharmacy did not receive a valid prescription from the provider and had requested a new prescription on 9/9/24, which had not yet been received. Staff members, including an LPN and the LPN Staffing Coordinator, indicated that if a medication was unavailable, the nurse should follow up with the pharmacy and check the automated medication dispensing system. It was noted that a fentanyl patch was available in the dispensing system, but staff did not follow up with the pharmacy to obtain authorization to remove it, as they were unaware of the lack of a valid prescription.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor two residents who were prescribed psychotropic medications, leading to a risk of unnecessary medication use. Resident 87, admitted with bipolar disorder, was receiving duloxetine for depression without proper monitoring for adverse reactions or behaviors. Despite the care plan indicating the need for monitoring, there was no system in place to track the effectiveness or side effects of the antidepressant. Staff acknowledged the lack of documentation and monitoring for the resident's medication use. Resident 164, who was on hospice care, was prescribed Ativan PRN for anxiety without a developed care plan for its use or documentation of non-pharmacological interventions prior to administration. Additionally, there was no monitoring for side effects of the antianxiety and antipsychotic medications prescribed. Staff admitted to the absence of a care plan and monitoring system for these medications, indicating a gap in the facility's medication management practices.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician or resident representative regarding refusals and changes in condition for three residents. Resident 55, admitted with chest pain, refused a prescribed lidocaine patch for pain relief nine times over nine days, yet there was no documentation that the physician was informed of these refusals. The facility administrator confirmed that the physician was not notified during this period. Resident 86, admitted with a UTI and paraplegia, had a catheter dislodged and was sent to the hospital for reinsertion. The family was not notified immediately, as the staff chose to wait until later in the morning. The unit manager acknowledged that the family should have been informed immediately. Resident 165, admitted with pneumonia, experienced a significant drop in oxygen levels after removing their oxygen device multiple times during the night. Despite the critical drop in oxygen levels, the physician was not notified, as confirmed by the DNS and the staff involved.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an allegation of elopement in a timely manner to the State Survey Agency for one of the sampled residents. The resident, who was admitted with diagnoses including dementia, stroke, alcohol abuse, and seizures, left the facility without authorization. The incident occurred on September 6, 2024, but was not reported to the State Agency until September 9, 2024. Interviews with the facility's Administrator, Director of Nursing Services, and Regional Nurse revealed that the staff did not inform the facility administration about the elopement until September 9, 2024, three days after the incident occurred.
Falsification of Documentation by CMA
Penalty
Summary
The facility failed to ensure that staff did not falsify documentation, which placed residents at risk for adverse medication reactions. Specifically, a Certified Medication Aide (CMA), identified as Staff 20, did not obtain the required vital signs before administering medication to a resident. The resident, who was admitted with a diagnosis of paraplegia and was cognitively intact, was prescribed Baclofen, a muscle relaxant, to be administered three times a day. The medication was to be withheld if the resident's systolic blood pressure was less than 100. On the day of the incident, Staff 20 documented a blood pressure reading of 100/68 and administered the medication, despite the actual blood pressure being 89/65. An investigation revealed that Staff 20 did not take the resident's blood pressure at the time of medication administration but instead guessed the reading based on the morning's measurement. This action was confirmed when Staff 19, an LPN, was informed by a CNA of the resident's actual blood pressure and questioned Staff 20 about the discrepancy. Staff 20 admitted to fabricating the blood pressure reading and entering it into the Medication Administration Record (MAR). This falsification of documentation led to the administration of medication under inappropriate conditions, posing a risk to the resident's health.
Inadequate Grooming and Bathing Care for Residents
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming for three residents, leading to unmet needs. Resident 62, admitted with chronic pain, was supposed to receive showers twice a week according to their care plan. However, documentation revealed that the resident only received three showers in May 2024, and the resident reported receiving only four showers a month, which was insufficient. Staff members confirmed that there was not enough time or staff to complete all showers as planned. Similarly, Resident 86, who required extensive assistance due to depression and paraplegia, was not consistently assisted with bathing and shaving. The resident preferred to be clean-shaven but was observed with facial hair, and staff acknowledged that the resident's personal hygiene needs were not met due to inconsistent staff assignments and lack of understanding of the resident's needs. Resident 98, who was cognitively intact and required assistance with most activities of daily living following a stroke, also experienced inadequate bathing care. The resident was scheduled for two showers a week but received only one bed bath and one sponge bath, with refusals documented on two occasions. Staff reported that there was insufficient time to complete all tasks due to staffing issues, and no additional attempts to bathe the resident were documented. The lack of documentation and follow-up on bathing refusals further highlighted the facility's failure to meet the resident's grooming needs.
Inadequate Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to provide adequate care for residents with bowel and bladder needs, as evidenced by the experiences of Resident 24. This resident, who was cognitively intact and admitted with a diagnosis of heart disease, reported waiting up to 30 minutes for staff to respond to call lights for bowel and bladder care. Observations confirmed delays in response times, with staff taking over 20 minutes to address the resident's needs, resulting in the resident experiencing frustration and emotional stress. Staff interviews corroborated the resident's account, highlighting staffing challenges that impeded timely care. Resident 86, admitted with depression and paraplegia, experienced issues with catheter care. The resident had a suprapubic catheter that was not properly monitored after a change, leading to the catheter slipping out during routine care. Staff were unaware of the catheter replacement and failed to conduct necessary assessments or obtain hospital records following an emergency room visit for catheter reinsertion. This lack of monitoring and documentation contributed to the deficiency in care. Resident 164, who had fragile skin and an allergy to aloe, suffered from inappropriate incontinent care. Despite a care plan specifying the use of non-aloe wipes, staff used the wrong wipes, causing redness and pain. The special wipes were not easily accessible, and there was no signage to remind staff of the resident's needs. Staff interviews revealed a lack of awareness and communication regarding the resident's specific care requirements, leading to the use of inappropriate products and subsequent discomfort for the resident.
Failure to Arrange Specialized Physician Appointments
Penalty
Summary
The facility failed to obtain specialized physician appointments for a resident, which was identified during a survey following a public complaint. The complaint, received on May 2, 2024, alleged that the facility did not arrange for the resident's nerve block procedure as per physician orders. The resident, admitted in June 2022, had diagnoses including chronic pain. A physician order dated January 13, 2023, indicated the need for referrals to neurology and cardiology for evaluation and a bilateral ultrasound-guided glenohumeral injection. On September 13, 2024, a staff member from Social Services acknowledged that the directive to schedule these appointments had not been addressed.
Significant Medication Error Due to Inaccurate Blood Pressure Documentation
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with a diagnosis of paraplegia. The resident was prescribed Baclofen, a muscle relaxant, to be administered three times a day, with instructions to hold the medication if the systolic blood pressure was less than 100. On the day of the incident, the resident's blood pressure was documented as 100/68, and the medication was administered. However, an investigation revealed that the actual blood pressure was 89/65, indicating that the medication should not have been given. The error occurred because Staff 20, a CMA, did not obtain the resident's blood pressure at the time of medication administration. Instead, she relied on the morning blood pressure reading and guessed the afternoon reading, which she then documented inaccurately. This action led to the administration of the medication despite the resident's chronic low blood pressure, which was significantly lower than the threshold for withholding the medication. Staff 19, an LPN, was informed by a CNA about the resident's low blood pressure, which prompted the investigation into the incident.
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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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