Marquis Mill Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 1475 Se 100th Avenue, Portland, Oregon 97216
- CMS Provider Number
- 385214
- Inspections on file
- 20
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Marquis Mill Park during CMS and state inspections, most recent first.
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.
Failure to Assess Resident for Self-Administration of Medications: A cognitively intact resident with ESRD had a weekly pill organizer left on the bedside table with multiple pills still inside, but no current assessment was completed to determine whether the resident could safely self-administer meds. Staff reported that medications found in a resident’s room should be reported to a nurse, and the RNCM and DNS acknowledged the resident had not been assessed for self-administration.
A resident admitted with cancer and noted to be cognitively intact had an advance directive discussed at a care conference, with family expected to provide a copy to the facility. However, the advance directive was not filed in the resident’s chart, and Social Services staff reported no follow-up was completed to obtain it.
Failure to notify the State LTC Ombudsman office of a resident’s discharge. A resident admitted with respiratory failure was discharged, but the clinical record did not show Ombudsman notification, and the discharge list sent to the Ombudsman did not include the resident. The BOM verified the resident was omitted from the list, and the Administrator stated that a complete list of discharged residents was to be sent.
A resident admitted with a stroke had an oxygen filter that was documented as cleaned by staff, but it was later observed coated with gray/brown dust. A CNA said nurses were responsible for cleaning the filters, an LPN said the oxygen company managed the equipment, and the RNCM verified the dust likely did not accumulate after the last documented cleaning. The DNS stated staff were to clean oxygen filters weekly.
Failure to Notify Resident Representative of Change in Condition: A resident with a hip fracture repair, dementia, and anxiety developed a suspected surgical site infection, and the LPN notified the NP and RNCM, who started cephalexin. The resident’s designated family contact was not notified of the change in condition until later, despite the family member’s request to be informed of any change in condition and staff acknowledgment that a suspected infection required notification.
Misappropriation of Resident Property and Funds: A cognitively intact resident with a femur fx and MDD was found to have missing credit and debit cards after receiving fraud alerts. Surveillance and record review showed a former maintenance assistant entered the resident’s room without a documented work order and used the resident’s cards for gas and online purchases totaling over $1,300, causing financial loss and emotional distress.
During a COVID-19 outbreak, a facility failed to follow proper infection control practices, with staff not adhering to PPE protocols and not disinfecting shared medical equipment. Observations showed staff improperly handling PPE and sharing face shields, increasing the risk of cross-contamination. Interviews revealed confusion among staff regarding PPE use, contributing to the deficiency.
The facility inaccurately coded the MDS for two residents, one regarding dental status and the other discharge location. A resident was incorrectly noted as having natural teeth despite being edentulous, and another was wrongly coded as hospitalized instead of discharged home. These errors were confirmed by staff and could lead to unmet care needs.
A resident with respiratory failure required assistance with hearing aids, but the facility failed to include this in the care plan. Family members found the aids uncharged, and staff confirmed the absence of guidance in the care plan, leading to communication barriers.
A facility failed to ensure timely podiatry care for a resident with diabetes and onychomycosis. Despite physician orders for podiatry care in October, no follow-up was made after a message was left in November. By January, the resident had a foot wound and was unsure about the need for podiatry care, with staff confirming no further scheduling efforts had been made.
A facility failed to provide trauma-informed care to a resident with PTSD, as required by their policy. Despite the resident's admission records indicating PTSD, staff were unaware of the diagnosis and did not follow up with the resident, family, or providers. The resident expressed that staff did not inquire about their trauma history, and staff interviews confirmed a lack of awareness and action regarding the resident's PTSD.
A resident with type 2 diabetes mellitus received insulin without proper priming of the insulin pens, as required by the manufacturer's instructions. An LPN administered insulin lispro and insulin glargine without performing the necessary safety steps, resulting in a medication administration error rate of 6.9%. The LPN was unaware of the priming requirement, and the DNS confirmed that staff are expected to follow these instructions.
A facility failed to provide necessary behavioral health services and develop an individualized care plan for a resident with adjustment disorder and depression following an amputation. Despite the resident's openness to non-pharmacological interventions, no psychosocial support was offered, and staff were unsure how to address the resident's emotional needs.
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.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications. Resident 9 was admitted with end stage renal disease and had a Quarterly MDS with a BIMS score of 14, indicating cognitive intactness. However, the clinical record contained no current self-administration of medication assessment to determine whether the resident could safely self-administer medications. Observations showed a large weekly pill organizer for Monday through Sunday, three times per day, sitting on the resident’s bedside table with 16 of 21 slots filled with pills. The resident stated the pill organizer had been on the bedside table for about a week and that some pills were not taken during a planned trip away from the facility. Progress notes showed the resident left the facility with packed medications and later returned. Staff interviews indicated CNAs were expected to notify a nurse if medications were found in a resident’s room, and an LPN later removed the pill organizer because the resident had not been assessed for self-administration. The RNCM and DNS both acknowledged the resident was not assessed for self-administering medications and stated medications should be kept in a locked location unless properly authorized.
Advance Directive Not Filed in Resident Record
Penalty
Summary
The facility failed to ensure that Resident 5’s advance directive was filed in the clinical record. Resident 5 was admitted with a diagnosis of cancer and the 12/22/25 admission MDS indicated the resident was cognitively intact. The 3/26/26 multidisciplinary care conference documented that the resident and family participated and noted that the resident had an advance directive, with family to provide a copy to the facility. However, the clinical record did not contain the advance directive. During interview, Resident 5 stated having an advance directive, and Social Services staff stated the family was supposed to provide it but no follow-up was completed. The Social Services Director stated staff were to follow up with family to ensure the advance directive was in the resident’s clinical record and document attempts to call family, and the Administrator stated the advance directive should be in the clinical record as soon as able.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure the State Long-Term Care Ombudsman office was notified of a resident’s discharge for 1 of 1 sampled resident reviewed for discharge. Resident 85 was admitted in 2/2026 with a diagnosis of respiratory failure and was discharged in 2/2026, but the clinical record did not show that the Ombudsman office was notified of the discharge. The facility’s 1/1/26 through 3/31/26 Discharges list did not include Resident 85, and this was the list used to notify the Ombudsman office of discharged residents. On 4/23/26, the Business Office Manager verified that Resident 85 was not included on the discharge list sent to the Ombudsman office, and on 4/24/26 the Administrator stated that a complete list of discharged residents was to be sent to the Ombudsman office.
Oxygen Filter Not Cleaned as Required
Penalty
Summary
The facility failed to ensure a resident's oxygen equipment was cleaned for Resident 5, who was admitted in 12/2025 with a diagnosis of stroke. Resident 5's task form showed staff cleaned the oxygen filter on 4/17/26, but on 4/20/26 the oxygen filter was observed with gray/brown dust coating it. During interviews, a CNA stated nurses were responsible for cleaning oxygen filters, an LPN stated the oxygen company managed the oxygen equipment, and the RNCM verified the filter was coated with dust and that the amount of dust likely did not build up after 4/17/26. The DNS later stated staff were to clean the oxygen filters weekly.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident representative after a change of condition for one resident who was admitted with diagnoses including surgical treatment after a hip fracture, dementia, and an anxiety disorder. A Resident Designation Form dated 11/8/24 stated that Witness 2 was to be contacted in case of emergency. On 12/3/24, a Skilled Nursing Progress Note documented that the resident developed a new possible infection at the surgical site of the left hip. The LPN notified the NP and RNCM, and the NP directed the LPN to start cephalexin for the suspected wound infection. The physician order directed cephalexin to begin on 12/3/25, and the MAR showed the antibiotic was started on the evening of 12/3/25. A progress note dated 12/5/24 showed the RNCM contacted the resident’s family regarding the suspected infection and the antibiotic. The resident’s family member stated she/he requested notification of any change of condition and was not notified when the suspected infection occurred. The LPN stated she made the RNCM aware of the suspected infection and was not aware whether the family was notified. The RNCM stated family members were contacted when a resident experiences a change of condition, but confirmed the emergency contact was not alerted until 12/5/24. The DNS confirmed a potential infection was a change of condition and the emergency contact should have been contacted on 12/3/24.
Misappropriation of Resident Property and Funds
Penalty
Summary
The facility failed to protect a cognitively intact resident from misappropriation of property and money. Resident 86 was admitted with diagnoses including a right femur fracture and major depressive disorder, and the 7/31/25 MDS assessed the resident as cognitively intact. The resident later received fraud alerts from financial institutions and discovered two credit cards and one debit card missing from the room. The resident and family reported that Staff 10, a former maintenance assistant, had entered the room multiple times over the prior weeks without a clear request, reportedly to check equipment. Record review and the facility’s investigation showed fraudulent charges totaling over $1,300 between 8/4/25 and 8/16/25, including a gas station charge in the same town where Staff 10 lived and miscellaneous online purchases. Video surveillance confirmed Staff 10 used the resident’s credit and debit cards at a local gas station and for online purchases, and also showed Staff 10 entering the resident’s room on multiple occasions without a documented work order or request for maintenance services. The resident experienced financial loss and emotional distress related to the unauthorized use of personal financial accounts, and the resident elected to move rooms due to concerns for personal safety and security.
Inadequate Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to proper infection control practices during a COVID-19 outbreak, affecting two of the four halls reviewed. Observations revealed that staff did not consistently follow the CDC's guidelines for Transmission-Based Precautions. For instance, a CNA was observed exiting a room with a respirator and goggles improperly handled, failing to perform hand hygiene before donning a new respirator. Another LPN entered a room without the necessary eye protection and did not change the respirator after exiting a COVID-19 positive room, indicating a lack of understanding of the required PPE protocols. Further observations highlighted that staff were not disinfecting shared medical equipment between uses, increasing the risk of cross-contamination. A CNA was seen using a blood pressure cuff, stethoscope, thermometer, and oximeter on multiple residents without proper disinfection. Additionally, face shields were improperly stored and shared among staff, contrary to the facility's policy that each TBP room should have dedicated equipment. Interviews with staff revealed confusion and non-compliance with PPE protocols. Some staff members believed it was acceptable to store used face shields with clean PPE or to reuse respirators across different rooms. The facility's DNS and DNS in training acknowledged these practices were against the expected protocols and recognized the risk of contamination and infection spread due to these lapses. The facility's first COVID-19 case was identified earlier in the month, underscoring the urgency of adhering to infection control measures.
Removal Plan
- Immediate staff training was initiated by the DNS and Administrator on COVID transmission protocols, proper use of PPE (donning, doffing and reuse), storage and handling of PPE, disinfecting and use of equipment.
- Staff who received training included CNAs, nurses, housekeeping, laundry, maintenance, administrative staff, agency staff and contracted staff.
- Staff training was done immediately for all staff in the facility then at each shift change.
- Documentation of training would include a sign in sheet and a PPE competency validation form.
- Continued training would be conducted at each shift change and/or 1:1 until all staff received training.
- For staff who were on leave, training would be provided prior to returning to work.
- Facility will have a quality assurance meeting with the committee (Medical Director, Infection Preventionist, DNS, Administrator and other interdisciplinary members) to review policies and procedures on TBP and COVID-19 precautions, including proper use of PPE, storage and equipment use.
- DNS and Infection Preventionist will conduct visual audits every shift to ensure continued compliance with COVID and TBP requirements.
- Audits will be reviewed by the quality assurance team to ensure ongoing compliance.
Inaccurate MDS Coding for Dental and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to potential risks for unmet care needs. Resident 6, admitted with kidney failure, was inaccurately coded as having natural teeth on the Admission MDS, despite being edentulous and using dentures. This discrepancy was confirmed by staff observations and interviews, revealing that the resident had been without teeth for over a decade. The error in coding was acknowledged by the facility's staff, indicating a lapse in the accurate assessment of the resident's dental status. Similarly, Resident 65, admitted with a urinary tract infection, was incorrectly coded as hospitalized on the Discharge MDS, although the resident was discharged home. This error was confirmed upon review of the resident's health record by the Director of Nursing Services (DNS). The inaccurate coding of the discharge location highlights a failure in ensuring the MDS accurately reflected the resident's discharge status, which could lead to miscommunication and potential care planning issues.
Failure to Implement Care Plan for Hearing Aids
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's use of hearing aids, which was necessary for effective communication and hearing. The resident, admitted with a diagnosis of respiratory failure, required assistance with charging their hearing aids at night. However, the care plan did not include any information or instructions regarding the management of the hearing aids. This oversight was confirmed through interviews and observations, where it was noted that the hearing aids were often left in the resident's ears overnight and were not charged properly. Family members and staff interviews revealed that the resident's hearing aids were not being managed according to any documented plan, leading to communication barriers. The family member reported finding the hearing aids still in the resident's ears during morning visits, and staff confirmed the absence of guidance in the care plan. Observations showed that the hearing aids were not charged, as indicated by the blinking green light on the charging station. The Director of Nursing Services confirmed the lack of a care plan addressing the resident's hearing aid needs.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes and onychomycosis, as evidenced by the lack of follow-up on a podiatry appointment. The resident was admitted in August 2024 and was cognitively intact. Physician orders from October 2024 indicated the need for podiatry care, but after a message was left with the podiatrist in November 2024, no further efforts were made to schedule the appointment. By January 2025, the resident had a wound on their right foot and was unsure about the need for podiatry care. Staff confirmed that no follow-up actions had been taken since November 2024, despite the continued need for the resident to see a podiatrist.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, as required by their Trauma Informed Care Policy. The policy mandates that nursing staff, social services, and the attending physician identify individuals with a history of trauma during the initial assessment and develop a person-centered care plan. However, despite the resident's admission records indicating an active diagnosis of PTSD, there was no evidence in the clinical record that staff were aware of this diagnosis or attempted to follow up with the resident, family members, or medical providers regarding the resident's PTSD. Observations and interviews revealed that the resident tearfully recounted experiences of extreme violence and expressed that facility staff did not inquire about their trauma history. Staff members, including CNAs and social services directors, were unaware of the resident's PTSD diagnosis and did not reapproach the resident or reach out to family or providers for additional information. The Director of Nursing Services stated that residents with a PTSD diagnosis should have a related care plan and that staff should contact family members if residents decline to discuss their trauma, which was not done in this case.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 6.9% error rate. This was identified during an observation of medication administration for a resident with type 2 diabetes mellitus. The resident's physician orders included insulin lispro and insulin glargine, both of which require specific safety steps for priming before administration. However, during the medication administration, the LPN did not perform the necessary priming steps as outlined in the manufacturer's instructions for both insulin pens. The LPN was observed dialing the dose knob to the required units for both insulin lispro and insulin glargine without priming the pens. Upon inquiry, the LPN admitted to being unaware of the priming requirement and acknowledged not performing the safety steps. The Director of Nursing Services was informed of the oversight and stated that staff are expected to follow the manufacturer's instructions for priming insulin pens before administration.
Failure to Address Resident's Behavioral and Emotional Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with adjustment disorder with anxiety and depressed mood following a surgical amputation. The resident, who was admitted in December 2024, expressed feelings of depression and anxiety related to the loss of a limb. Despite these expressions and a documented increase in depressive symptoms, the facility did not offer any behavioral health services, develop an individualized care plan, or conduct ongoing monitoring of the resident's mood to address their emotional and psychosocial needs. Observations and interviews revealed that the resident was open to non-pharmacological psychosocial interventions, such as counseling, but reported that no such support was offered by the facility. A family member corroborated the lack of mood support, and a CNA noted the resident's sadness but was unsure of the cause or how to address it. The Social Services Director acknowledged the resident's depression but did not recall offering any psychosocial support, indicating a lapse in the facility's responsibility to address the resident's behavioral and emotional needs.
Latest citations in Oregon
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
