Marquis Piedmont Post Acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 319 Ne Russet, Portland, Oregon 97211
- CMS Provider Number
- 385208
- Inspections on file
- 17
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Marquis Piedmont Post Acute Rehab during CMS and state inspections, most recent first.
Unlocked medication and treatment carts were observed unattended on multiple halls, with staff not in view of the carts. The carts contained resident medications and treatment supplies, including insulin and insulin supplies, eye drops, inhalers, prescribed creams and lotions, wound care supplies, nebulizer medications, and other resident items. Staff confirmed the carts were unlocked, and the DNS stated carts were expected to remain locked when not in use.
Failure to assess a cognitively intact resident with depression and ESRD for safe self-administration of meds. Surveyors observed empty Imodium packs and other pill packs in the resident’s room, and a CMA left a tablet in a cup with the resident despite no documented self-administration assessment or directions allowing bedside meds. The resident stated staff often leave meds for later, and the RCM and DNS confirmed the resident had not been assessed.
A resident with CHF and epididymitis was transferred to the hospital for scrotal swelling, but the clinical record did not show that a written bed hold notice was given to the resident or representative. The DNS stated the charge nurse was responsible for providing the bed hold policy at transfer, and the Administrator confirmed the form was not completed.
Failure to provide fingernail care for a resident with DM and ESRD. The resident was cognitively intact, had long pointed fingernails with dark substance under them, and stated assistance was needed because of the DM diagnosis and that nail trimming had not been offered. The chart had no care plan direction for staff or an RN to trim the nails and no documentation that the task was completed; staff stated only an RN could perform the nail care for residents with DM.
Failure to Follow Fall Safety Interventions: A resident with dementia, anxiety disorder, stroke history, and a history of falls was care planned as high fall risk with interventions including no assistive devices at bedside, bed in the lowest position, and a fall mat at bedside. Staff observed the resident in bed with the walker within reach, the bed not in the lowest position, and no fall mat in place, and an RNCM confirmed these were the planned interventions.
A resident with PTSD, moderate depression, and intact cognition did not have PTSD triggers or interventions addressed in the care plan, social services form, or care conference. Staff were unaware of the resident’s triggers, did not complete a behavior assessment related to PTSD, and did not follow up after counseling was initially offered and declined. The resident reported multiple trauma-related triggers, distress during a fire drill when the bedroom door was closed, and anxiety when staff attempted to close the door during care.
Failure to Provide Dental Services: A resident admitted with ESRD and DM2 was documented as cognitively intact with no dental issues, but later was observed with several broken and missing upper front teeth and reported cavities that made chewing challenging and sometimes painful. Staff interviews showed inconsistent understanding of the resident’s oral care needs, with CNAs saying they only reminded the resident to brush after meals and an LPN unaware of missing teeth or cavities; the DNS later found missing, cracked, and decayed teeth that needed to be addressed.
Failure to protect a resident from physical abuse occurred when two cognitively intact residents had an escalating dispute over a loud TV and one resident entered the other’s room. The interaction turned physical, resulting in a bloody nose for the resident with hearing impairment and anticoagulant use. Both residents later described the event as a misunderstanding, but staff confirmed the resident was struck in the face during the altercation.
A facility failed to update a resident's care plan to reflect changes in nutritional and positioning needs. The resident, admitted with a stroke and stage 4 pressure injury, was observed using a regular cup without assistance, contrary to the care plan's requirement for 1:1 assistance and adaptive equipment. Staff interviews revealed a lack of awareness of the care plan, and the hand splint was discontinued due to pain, yet the care plan was not revised.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a stage 4 pressure injury, as staff did not wear gowns during high-contact care activities. Despite the care plan indicating the need for EBP, staff were observed providing care without the required protective equipment, and some were unable to explain the EBP requirements.
The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delays in care such as showers and toileting. Residents and staff reported challenges due to understaffing, with staffing based on minimum ratios rather than resident acuity. This led to unmet care needs, as confirmed by the facility's administrator and staffing coordinator.
The facility failed to accurately complete the Direct Care Staff Daily Report (DCSDR) postings, which did not reflect the correct number of staff working and their hours for 37 consecutive days. This issue was confirmed by the DNS, who acknowledged the inaccuracies in the staffing reports.
A resident with diabetes and edema was denied assistance with personal hygiene by a CNA, who made a demeaning comment. The charge nurse reassigned the task, and the resident received care. An investigation revealed similar complaints from other residents about the CNA's behavior.
A facility failed to provide a dependent resident with the scheduled showers, resulting in unmet needs and loss of dignity. The resident, with multiple sclerosis and morbid obesity, was supposed to receive showers twice a week but only received five out of nine scheduled showers in a month. Staff confirmed that missed showers were not rescheduled due to staffing issues, and there was no documentation of additional bathing opportunities.
Unlocked Medication and Treatment Carts Left Unattended
Penalty
Summary
The facility failed to ensure medications and biologicals were secured in accordance with its medication cart policy, which required medication carts to be securely locked at all times when out of the nurse’s view. During observation, an unlocked treatment cart was found on the North Hall while the nurse was not in view. The cart contained multiple drawers with resident care items, including insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. Staff confirmed the cart was unlocked and contained medications and treatment supplies, and the DNS stated it was her expectation that all medication and treatment carts remain locked when not in use. A second unlocked medication cart was observed on the North Hall while the CMA was not in view of the cart. The cart contained multiple drawers with medications, including eye drops, inhalers, nasal sprays, resident prescribed medications, over-the-counter medications, and overflow medications. In another observation, an unlocked treatment cart was found on [NAME] Hall with the nurse not in view, and it also contained insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. An additional unlocked medication cart was observed near the social services office and room [ROOM NUMBER] with no staff in view; the CMA later acknowledged leaving it unattended and unlocked, and the cart contained resident medications, insulin supplies, eye drops, and inhalers.
Failure to Assess Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication. Resident 29 was admitted with diagnoses including depression and end stage renal failure, and the 12/17/25 MDS assessed the resident as cognitively intact. During observations on 4/6/26, 4/7/26, and 4/8/26, surveyors found empty six-packs of Imodium on the resident’s dresser and sink counter, as well as empty individual pill packs on the sink counter and floor by the bed. A review of the medical record on 4/8/26 did not show any indication that the resident was safe to self-administer medications. On 4/8/26, a CMA entered the resident’s room, left a white tablet in a small clear plastic pill cup with the resident, and left the room. The resident stated that staff leave this pill for later after meals and often leave other pills for the resident to take later if not taken at the time. The CMA stated some residents had medications left at bedside to self-administer, but confirmed this resident did not have directions allowing bedside medication. The RCM stated staff were expected not to leave medications in a resident’s room unless the resident had a Self-Administration Assessment, and confirmed this resident did not have one. The DNS also acknowledged that residents who wished to self-administer medications were expected to be assessed for safety and that no medication should be left at bedside without an assessment.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy for Resident 4 when the resident was transferred to the hospital on 4/3/26 for evaluation and treatment of scrotal swelling. Resident 4 had been admitted in 2/2026 with diagnoses of congestive heart failure and epididymitis. The clinical record showed the provider was notified and orders were received to send the resident to the hospital, but there was no documentation that a written bed hold notice was given to the resident or the resident's representative. On 4/10/26 at 11:30 AM, the DNS stated the charge nurse was responsible for providing the bed hold policy when residents were sent to the hospital and confirmed there was no documentation that Resident 4 received the notice. On 4/10/26 at 11:40 AM, the Administrator also confirmed the bed hold policy was not completed at the time of transfer.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who was unable to perform the task independently. The resident was admitted with diagnoses including diabetes and end stage renal failure, and the admission MDS assessed the resident as cognitively intact. During observation, the resident was found with long pointed fingernails and dark substance under the nails, and stated that assistance was needed to trim the fingernails because of the diabetes diagnosis, that the resident wanted the nails trimmed, and that assistance had not been offered. Record review showed no directions in the health record for staff to assist with or offer fingernail trimming and no documentation that the fingernails had been completed. Staff interviews confirmed that a CNA did not trim fingernails for residents with diabetes, that only an RN could trim the fingernails for health and safety reasons, and that the resident did not have a plan of care directing a licensed nurse to perform the task or documentation showing the nail trim was completed.
Failure to Follow Fall Safety Interventions
Penalty
Summary
The facility failed to provide care planned safety interventions for Resident 25, who was admitted in 8/2024 with diagnoses of dementia and anxiety disorder. A 3/16/26 Quarterly MDS showed a BIMS of 14, indicating the resident was cognitively intact. A 3/27/26 fall care plan identified the resident as high risk for falls due to acute medical conditions, stroke, and a history of falls, and included interventions of no assistive devices at bedside, bed in the lowest position, and a fall mat at bedside. Random observations from 4/6/26 through 4/9/26 showed Resident 25 in bed with the walker at bedside and within reach, the bed not in the lowest position, and no fall mat in place. On 4/9/26, a CNA and an RN both entered the room, observed the resident in bed, and confirmed the walker was within reach, the bed was not in the lowest position, and a fall mat was not in place. The RNCM confirmed the resident was care planned to have no assistive devices within reach, the bed in the lowest position, and a fall mat at bedside. The DNS stated it was her expectation that staff follow and implement all care planned fall interventions.
Failure to Address PTSD Triggers and Services
Penalty
Summary
The facility failed to identify PTSD triggers and failed to provide treatment and services to address distress related to PTSD for one resident with a documented PTSD diagnosis. The resident was admitted with diagnoses including PTSD, had a BIMS score of 15 indicating cognitive intactness, and the Mood and Behavior CAA indicated psychosocial well-being would be addressed in the care plan with a goal of maintaining current functioning and avoiding complications. However, the 3/18/26 care plan did not address PTSD triggers or interventions, and the social services admission form did not address the resident’s PTSD diagnosis, triggers, or interventions despite a PHQ-2 to 9 score of 15 out of 27 indicating moderate depression. Progress notes documented that the resident was distressed, had increased anxiety, and expressed mental health concerns, and the resident requested to check in with Social Services. The 3/24/26 care conference did not address the PTSD diagnosis, triggers, or interventions. The record also revealed no evidence that the resident refused to discuss the PTSD diagnosis and no follow-up was completed with Social Services. Staff interviews showed multiple staff members were unaware of the PTSD diagnosis or the resident’s triggers, and the RNCM and DNS acknowledged that PTSD triggers and related interventions were not included in the care plan and that the resident had not received PTSD-related services. The resident stated staff did not address the PTSD diagnosis, triggers, or interventions and reported childhood trauma including abandonment, sex trafficking, substance abuse, sexual abuse, and physical abuse. The resident identified triggers including closed doors, windows, curtains, opened bathroom doors, perfumes, supplies with high alcoholic content, chicken pot pies, and tea, and stated closed doors made the resident feel isolated, trapped, and scared. The resident also reported increased anxiety during a fire drill when the bedroom door was closed and described distress lasting for hours afterward. During observation, staff attempted to close the resident’s door while providing care, and the resident stated that having the door and curtain opened was the resident’s preference; staff did not respond and walked away.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with diagnoses including end stage renal disease and type 2 diabetes. The resident’s admission MDS indicated cognitive intactness and no missing, cracked, or decayed teeth, and the nursing admission assessment documented no dental issues. The care plan later indicated the resident required constant supervision and physical assistance to complete oral hygiene tasks. During observation, the resident was found to have several broken and missing upper front teeth and stated that most of the upper teeth were missing and that cavities made chewing challenging and sometimes painful. The resident also stated staff never examined the inside of the mouth or asked about dental health. Staff interviews showed differing understandings of the resident’s oral care needs: CNAs reported only reminding the resident to brush after meals, one LPN stated the resident was fairly independent and required set-up assistance, and another LPN was unaware of missing teeth or cavities. The DNS later examined the resident’s dentition and stated the resident had missing, cracked, and decayed teeth that needed to be addressed.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse in an incident involving two cognitively intact residents. One resident had diagnoses including dementia, hearing deficit, and use of an anticoagulant medication, while the other resident had diagnoses including diabetes and visual deficit. The event occurred when the resident with hearing impairment entered the other resident’s room because the television was loud and asked for the volume to be turned down. According to the resident-to-resident event assessment, the interaction escalated after the resident in the room told the other resident to leave. The resident who entered the room did not understand the response because of the hearing impairment, and the situation resulted in the resident being struck in the face and sustaining a bloody nose. Staff assessed the injury and found no bruising or swelling, and progress notes documented daily monitoring with no further facial injury, pain, or discomfort. Later interviews showed both residents described the event as a misunderstanding. One resident reported that the other resident became upset and hit him/her in the face with a phone after the resident attempted to grab the phone, while the other resident stated the contact was unintentional and occurred while resisting the attempt to take the phone. Staff also stated the resident who was struck had a history of easy bruising and that the bloody nose occurred in the setting of anticoagulant use.
Failure to Update Care Plan for Resident's Nutritional and Positioning Needs
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect the needs of a resident, specifically in the areas of nutrition and positioning. Resident 37, who was admitted with a stroke and a stage 4 pressure injury, had a care plan indicating the need for 1:1 total assistance for meals and the use of adaptive equipment. However, observations from December 2 to December 5 revealed that the resident was drinking from a regular cup without assistance and no adaptive devices or hand splint were in use. Staff interviews confirmed that the resident's care plan was not updated to reflect the current needs, as the resident no longer required 1:1 assistance or adaptive equipment. Staff members were unaware of the care plan requirements, with one LPN stating that the resident only required supervision and encouragement during meals. Another staff member confirmed that the hand splint was discontinued due to causing pain, yet the care plan was not updated to reflect this change. This oversight placed the resident at risk of receiving unneeded assistance, as the care plan did not accurately represent the resident's current condition and needs.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident with a complex wound, specifically a stage 4 pressure injury, which placed residents at risk for exposure to infections. The facility's policy required the use of gloves and gowns during high-contact care activities such as transfers, wound care, peri-care, and dressing assistance for residents with catheters and complex wounds. However, during observations, staff members were seen providing care to the resident without donning the required gowns. On multiple occasions, staff members, including a CNA and NAs, assisted the resident with transfers and personal hygiene without wearing gowns, despite the care plan indicating the need for EBP due to the resident's risk of infection. When questioned, some staff members were unable to explain the EBP requirements, and others acknowledged their failure to wear gowns during care. The RNCM confirmed that staff were expected to wear gloves and gowns during these care activities for the resident.
Insufficient Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. On the dates reviewed, the facility had a census of 51 residents, with a significant number requiring extensive assistance for daily activities such as mechanical lift transfers, bathing, toileting, and dressing. Additionally, a large portion of the residents had behavioral health needs, were high fall risks, or required bariatric care. Despite these needs, staffing was based on the state's mandatory minimum ratios rather than the acuity needs of the residents, leading to unmet care needs. Multiple residents reported delays in receiving care, such as waiting hours for assistance with showers or toileting. Staff members confirmed the challenges posed by insufficient staffing, noting that when staff called out or did not show up, it was difficult to complete necessary tasks like taking vital signs, providing showers, and assisting with meals. The staffing coordinator and administrator acknowledged the reliance on minimum staffing ratios and the difficulties in maintaining adequate staffing levels, which contributed to the inability to provide timely and appropriate care to residents.
Inaccurate Staffing Reports
Penalty
Summary
The facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were thoroughly completed or accurately reflected the number of staff working and their hours worked for all 37 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the DCSDRs from 8/18/24 through 9/24/24 were incomplete or inaccurate. On 9/25/24, the Director of Nursing Services (DNS) acknowledged that the DCSDRs did not accurately include the hours staff members worked during the reviewed period.
Resident Dignity Compromised by CNA's Refusal to Assist
Penalty
Summary
The facility failed to treat residents in a dignified manner, specifically involving a resident who was denied assistance with personal hygiene by a CNA. The resident, who was cognitively intact and had diagnoses including diabetes and edema, requested help from the CNA after a bowel movement. The CNA refused to assist, making a demeaning comment, and insisted that the resident could manage on their own. The charge nurse intervened and reassigned the task to another CNA, who provided the necessary care. The incident was reported by the resident to the Social Services Director, who conducted interviews with other residents cared for by the same CNA. Two additional residents reported similar issues with the CNA's attitude and inappropriate comments. The facility's administrator confirmed that an investigation revealed the CNA had made rude comments to multiple residents.
Removal Plan
- All staff were educated on resident rights, respect, dignity, abuse and neglect.
- All staff completed written tests on their knowledge of resident rights.
- Dignity and respect audits were completed on residents.
- The quality assurance committee reviewed audits and grievances.
- Staff 19 no longer worked at the facility.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received the scheduled showers, which placed the resident at risk for unmet needs and loss of dignity. The resident, who was admitted with diagnoses including multiple sclerosis and morbid obesity, was dependent on staff for bathing and was scheduled to receive showers twice a week. However, the resident's bathing logs indicated that only five out of nine scheduled showers were provided during the month of August 2024. There was no documentation of additional bathing opportunities being offered when showers were missed. Interviews with the resident revealed that they had not been showered or had their hair washed for three weeks, and they reported refusing only one shower during that period. Staff members confirmed that missed or refused showers were typically not rescheduled due to staffing issues. The Director of Nursing Services acknowledged a miscommunication regarding the resident's showers, and the Administrator confirmed that there was no evidence of additional showering opportunities being offered when showers were missed or refused.
Latest citations in Oregon
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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