Regency Albany
Inspection history, citations, penalties and survey trends for this long-term care facility in Albany, Oregon.
- Location
- 805 19th Avenue Se, Albany, Oregon 97321
- CMS Provider Number
- 385220
- Inspections on file
- 22
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Regency Albany during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found in another resident's room engaged in inappropriate sexual contact, with no memory of the event and exhibiting unusual behavior afterward. Despite the incident and the other resident's history of inappropriate conduct, the facility did not implement or document any interventions to ensure safety, and the family was not promptly notified.
A resident's allegations of sexual and verbal abuse were not reported to the State Survey Agency within the required two-hour timeframe. The incidents were reported several days after they occurred, and the facility administrator confirmed the delay in reporting.
The facility failed to implement proper infection control and sanitation practices for residents with C-Diff and other infections. A resident with C-Diff was not placed on contact precautions timely, and staff used ineffective cleaning products. Another resident with a pressure ulcer received unsanitary wound care. Staff also failed to use PPE and proper hand hygiene during medication administration and high-contact care activities.
Two residents experienced verbal abuse by staff in a LTC facility. One resident, with anxiety and depression, was left feeling stripped of dignity after a CNA refused to get assistance during care. Another resident, with cerebral palsy, faced aggressive behavior from the Kitchen Manager during a grievance discussion. Witnesses confirmed the inappropriate conduct, leading to a delayed abuse investigation.
The facility failed to document and follow up on advance directives for several residents, including those with leg fractures, open wounds, and malnutrition. Despite providing advance directive packets during care conferences, there was no follow-up to ensure completion or documentation, placing residents at risk of not having their healthcare decisions honored.
The facility did not provide a homelike dining environment in three dining rooms. Meals were left on trays, and tables lacked decorations and tablecloths. The administrator acknowledged that meals should feel like home and trays should be removed unless requested by residents.
Facility staff failed to follow professional standards for medication administration and wound care, affecting four residents. An LPN administered medications late and without checking blood pressure, while another staff member provided inadequate wound care by not sanitizing hands or changing gloves. Additionally, a resident did not rinse their mouth after using an inhaler, and medications were given without proper timing or checks.
A long-term care facility reported a medication error rate of 18.92%, with errors including late administration, failure to check blood pressure, improper handling of medications, and not following specific medication instructions. These incidents involved residents with heart disease, respiratory failure, and thyroid disorder, and were attributed to a lack of guidance for LPNs on handling late medication administration.
A resident with Parkinson's disease and hand contractures was unable to use the facility's call light system, leading to unmet hydration needs. Despite a revised care plan, the resident had to yell for assistance, as confirmed by staff. The care plan lacked interventions for the resident's inability to use the call light and the need for frequent fluid offers, which was acknowledged by the Resident Care Manager.
A resident with bipolar disorder was inaccurately assessed regarding their discharge preferences. Despite the 9/28/24 Annual MDS indicating the resident did not want to discuss leaving the facility, interviews in November revealed the resident's desire to discharge to a home in Corvallis or Philomath. Staff confirmed the MDS information was incorrect, and the Regional Nurse acknowledged the error.
A resident with bipolar disorder was not provided with the necessary mental health evaluations as indicated by a PASRR Level 1 form. Despite the form highlighting serious mental illness indicators, the facility did not complete further evaluations, as acknowledged by the Social Service Manager.
A resident did not receive Catholic communion as scheduled due to a COVID outbreak, and the facility failed to document spiritual activity participation. The resident, with anxiety and depression, was cognitively intact and had minimal participation in spiritual activities over several months.
A facility failed to follow physician orders for insulin administration for a resident with diabetes. The resident had orders for 13 units of Humalog insulin before each meal, to be held if the CBG level was less than 100. However, an LPN held the insulin on two occasions when the CBG levels were above 100, due to a misunderstanding of standing orders. The Regional Nurse confirmed that the physician's orders should have been followed.
Two residents experienced deficiencies in pressure ulcer care and infection control. A resident's blisters were not documented as Stage 2 pressure ulcers, and another resident's wound care was compromised by an LPN's failure to maintain proper infection control practices, including not sanitizing hands and using soiled gloves and scissors.
The facility failed to ensure a safe environment for two residents, leading to potential injury risks. A resident with hoarding behaviors was injured by a falling bedside table, which was not promptly evaluated. Another resident, requiring fall mats due to chronic heart failure and dementia, did not have them in place as per their care plan, and the LPN was unaware of this omission.
A facility failed to provide and document catheter care for a resident with a Stage 4 pressure ulcer. The resident was observed with blood in the catheter tubing, which they stated was normal after a catheter change. However, there was no documentation in the Treatment Administration Record or Nursing Progress Notes for catheter care, such as flushing, cleaning, or changing the catheter. An LPN confirmed the lack of documentation in the resident's electronic record.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. A resident's CPAP mask was stored improperly with a used tissue nearby, while another's BiPAP machine was unsanitarily placed on a nightstand and bedrail. Staff acknowledged the inadequate storage practices and policy shortcomings.
A resident with cerebral palsy, dependent on staff for toileting, reported that caregivers made derogatory comments about the smell of their feces, leading to feelings of embarrassment and shame. The incident was not documented in the resident's progress notes, and the facility administrator confirmed the termination of the involved CNA's contract due to the inappropriate comment.
A facility failed to timely report an abuse allegation to the SSA for a resident with anxiety and depression. The incident occurred on a weekend, and the report was delayed due to a holiday, being sent the following Tuesday. The Administrator could not recall the report timing, and the DNS confirmed the delay, placing residents at risk.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, including Alzheimer's dementia and aphasia, from sexual abuse by another resident. The incident occurred when a CNA found the cognitively impaired resident in another resident's room, with her/his hands on the other resident's genitals. The resident was redirected to her/his own room and exhibited unusual behavior afterward, such as refusing care and being naked, which was not typical for this resident. The resident had no memory of the incident, and interviews confirmed the resident's inability to consent due to cognitive loss. The other resident involved had a history of making inappropriate comments and watching pornography in the facility. Despite the incident, a review of the medical record and care plan revealed that no interventions were implemented to ensure the safety of the resident following the event. There was no documentation of new safety measures or care plan updates addressing the incident or the behavior of the other resident. Additionally, the family was not promptly notified of the incident, and the administrator acknowledged that appropriate interventions were not put in place due to delayed reporting.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse and an allegation of verbal abuse involving one resident to the State Survey Agency within the required two-hour timeframe. Specifically, the incident of alleged sexual abuse occurred on 9/19/25 at 9:30 PM but was not reported until 9/22/25 at 2:51 PM, and the incident of alleged verbal abuse occurred on 7/19/25 at 12:41 PM but was not reported until 7/21/25 at 2:30 PM. These delays in reporting were confirmed by the facility administrator during an interview, who acknowledged that the incidents were not reported in a timely manner as required.
Inadequate Infection Control and Sanitation Practices
Penalty
Summary
The facility failed to implement transmission-based precautions and proper sanitation procedures for residents diagnosed with Clostridium difficile (C-Diff) and other infections. Resident 30, who was admitted with C-Diff, was not placed on appropriate contact precautions until several days after admission. Staff used ineffective cleaning products, such as Mycolio disinfectant wipes, which are not effective against C-Diff spores. Additionally, staff were observed not following proper hand hygiene and PPE protocols, leading to potential cross-contamination. Resident 10, who had a Stage 4 pressure ulcer, received wound care that did not adhere to sanitary practices. The staff member performing the wound care did not sanitize her hands before donning gloves, used soiled gloves to handle clean dressing supplies, and did not establish a clean field for the procedure. This lack of proper infection control measures could have compromised the resident's wound healing process. Other residents, such as Resident 19 and Resident 27, also experienced lapses in infection control. Staff were observed handling medications without sanitizing hands or using gloves, and failing to use PPE during high-contact care activities. Resident 195, who had a history of C-Diff, was not placed on contact precautions despite having multiple loose stools documented. These deficiencies highlight a systemic issue in the facility's infection prevention and control practices.
Removal Plan
- The hydration cart and vital sign equipment was sanitized to prevent the spread of infection.
- Current staff on shift were re-educated on transmission-based precautions relative to C-Diff per the CDC guidelines. Soap and water were reinforced as the standard for hand hygiene. Additional education was provided to include donning and doffing of PPE.
- Nurse management would complete ongoing Infection Control rounds on all three shifts, and then conduct random audits on all three shifts.
- New admissions to the facility would be reviewed by the Regional Nurse and IP to ensure that appropriate Infection Control measures were implemented, and Kardex and Care plans updated.
- Resident 30 had her/his room deep-cleaned as well as linens changed. Resident 30 declined a shower but accepted a full bed bath.
- Facility staff would be trained on providing hydration while facility residents were on transmission-based precautions including direction to obtain new water pitchers with each hydration pass.
- Current residents on transmission-based precautions had donning and doffing procedures added to the signage on the residents' doors for easy staff reference.
- Residents on transmission-based precautions were provided individual vital sign equipment while on transmission-based precautions.
- The facility IP would complete further training presented by Oregon Care partners on transmission-based precautions.
- Facility equipment for those on transmission-based precautions would be sanitized utilizing the Clorox Bleach Germicidal wipes with a contact time of three minutes. Education was provided to facility staff on cleansing techniques.
- The Regional Nurse would review the Infection Control portal to ensure that infections were care planned and appropriate precautions were implemented.
- A root cause analysis would be completed by the Governing Body and brought to the facility QAPI committee for review.
- The facility Executive Director was responsible for ensuring on-going compliance with the plan.
- Other residents in the facility with orders for transmission-based precautions were reviewed to validate they were placed on appropriate transmission-based precautions.
- Residents admitted to the facility were to be reviewed to validate that transmission-based precautions were implemented as appropriate, and PPE was available in the facility.
- Findings of the above audits would be reviewed with the medical director.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by incidents involving two residents. Resident 18, who was admitted with anxiety and depression, experienced an incident where a former agency CNA, Staff 38, refused to get assistance while helping the resident off a bedpan, resulting in a spill. Despite Resident 18's repeated requests for help, Staff 38 continued to clean the resident while making inappropriate comments, leaving the resident feeling stripped of dignity. The care plan for Resident 18 indicated a need for two-person assistance with bed mobility, which was not followed, leading to the incident. In another incident, Resident 1, who has cerebral palsy and is cognitively intact, reported a grievance after a confrontation with Staff 22, the Kitchen Manager. During a discussion about a meal that Resident 1 believed caused diarrhea, Staff 22 became defensive, raised his voice, and made aggressive comments. Witnesses, including other residents and staff, confirmed that Staff 22's behavior was inappropriate and could be considered verbal abuse. The incident was initially not recognized as abuse, but further discussions in a Resident Council meeting led to an investigation. Both incidents highlight a failure to adhere to expected standards of care and communication, resulting in residents feeling unsafe and disrespected. The facility did not place Resident 18 on alert for psychosocial harm following the incident, and there was a delay in recognizing the verbal abuse experienced by Resident 1. These deficiencies indicate a lack of appropriate response to allegations of abuse and a failure to protect residents from harm.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to obtain and document advance directives for four out of five sampled residents, which placed them at risk of not having their healthcare decisions honored. Resident 8 was admitted with a leg fracture and was noted to have a POLST that was not signed by a physician, and there was no advance directive in the electronic record despite indications otherwise. Resident 30, admitted with an open wound, was supposed to receive an advance directive booklet, but there was no documentation of this in the progress notes. Similarly, Resident 32, admitted with malnutrition, was expected to have an advance directive brought by a family member, but there was no documentation of this occurring. Resident 20, who was cognitively intact with a BIMS score of 15, had no advance directive documented in their medical record despite multiple care conferences over the course of a year. The Social Services Director, Staff 24, stated that advance directives were reviewed during care conferences, and packets were provided, but there was no follow-up on whether the directives were completed or documented. This lack of follow-up and documentation was consistent across the cases reviewed, indicating a systemic issue in the facility's handling of advance directives.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment in three dining rooms, as observed during a survey. In the Middle dining room, meals were left on delivery trays during the meal, and tables lacked decorations and tablecloths. In the Back dining room, meals were also left on trays, and no tablecloths were present. Similarly, in the Front dining room, meals were left on trays. The facility's administrator acknowledged that meals should feel like home and that trays and plate warmers should be removed unless requested by residents.
Medication and Wound Care Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for medication administration and wound care, affecting four residents. For Resident 9, the LPN administered Losartan late and without checking the resident's blood pressure, despite standing orders to hold the medication if the systolic blood pressure was below 100. The LPN admitted to not receiving guidance on handling late medication administration and acknowledged the oversight. Resident 10, who had a Stage 4 pressure ulcer, received inadequate wound care from the Resident Care Manager. The staff member did not sanitize hands before donning gloves, used contaminated surfaces for clean supplies, and failed to change gloves between handling soiled and clean items. The Regional Nurse confirmed that the staff member had recently completed a wound care class and should have known the correct procedures. For Resident 19, the LPN handled medications with unsanitized hands and did not follow the physician's order to have the resident rinse their mouth after using a Combivent inhaler. Additionally, the LPN relied on outdated blood pressure readings before administering Metoprolol, contrary to the facility's standing orders. Resident 33's medications were administered late, and the LPN did not check blood pressure before giving blood pressure medications. Furthermore, Levothyroxine was given after breakfast, contrary to guidelines that it should be taken on an empty stomach.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 18.92 percent error rate. This was due to seven errors out of 37 medication administration opportunities. One incident involved a resident with heart disease who was administered medications one hour and 45 minutes late without a blood pressure check, despite standing orders to hold blood pressure medications if systolic pressure was less than 100. The LPN involved did not receive guidance from management on procedures for running late with medication administration. Another incident involved a resident with respiratory failure, where an LPN failed to sanitize her hands or wear gloves before handling medications and did not ensure the resident rinsed their mouth after using a Combivent inhaler, as per physician orders. Additionally, a resident with heart disease and thyroid disorder received medications late, after breakfast, without a blood pressure check, and contrary to instructions for Levothyroxine to be taken on an empty stomach. The LPN involved was not informed about procedures for late medication administration.
Failure to Provide Appropriate Call Light System for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate call light system for a resident with Parkinson's disease and hand contractures, who was unable to use the button call light. The resident was admitted in February 2020 and had a care plan revised in November 2024, which included the use of a push pad call light within reach due to hand contractures. However, observations on multiple occasions revealed that the resident was unable to use the push pad call light and had to yell for assistance, indicating unmet needs for hydration as the resident expressed thirst and frustration. Staff interviews confirmed that the resident's care needs had increased, and the care plan did not address the resident's inability to use the call light or the need for frequent fluid offers. The Resident Care Manager acknowledged that the resident was not assessed before implementing the new push pad call light, and the care plan lacked necessary interventions to address the resident's fluid and call light needs. This oversight placed the resident at risk for unmet needs and lack of ability to call for assistance.
Inaccurate Assessment of Resident's Discharge Preferences
Penalty
Summary
The facility failed to accurately assess a resident's desire for discharge, leading to a deficiency in the assessment process. The resident, admitted in September 2020 with a diagnosis of bipolar disorder, was documented in the 9/28/24 Annual MDS as not wanting to discuss leaving the facility or returning to the community. However, interviews conducted on 11/4/24, 11/5/24, and 11/6/24 revealed that the resident expressed a desire to discharge to a home in Corvallis or Philomath. Staff members, including the Social Service Manager and Social Service Assistant, confirmed the resident's wish to leave the facility, acknowledging that the information on the 9/28/24 Annual MDS was incorrect. The Regional Nurse also acknowledged the error and indicated that corrections were being made to the MDS.
Failure to Conduct Required Mental Health Evaluations
Penalty
Summary
The facility failed to ensure that a resident with a serious mental illness received the necessary evaluations and care. The resident, admitted in September 2020, had a diagnosis of bipolar disorder. A PASRR Level 1 form dated September 17, 2024, indicated that the resident exhibited serious mental illness indicators and required further evaluation at the nursing facility. However, as acknowledged by the Social Service Manager on November 6, 2024, no further evaluations for mental illness were completed for the resident, leading to a deficiency in meeting the resident's mental health needs.
Failure to Provide Scheduled Spiritual Activities
Penalty
Summary
The facility failed to provide activities of choice for a resident, specifically Catholic communion, which was not received since the beginning of 2024. The resident, admitted in February 2022 with diagnoses including anxiety and depression, was cognitively intact as per a July 2024 Quarterly MDS. Despite Catholic communion being scheduled for November 5, 2024, the resident reported not receiving it. The Activities Director confirmed that no one was able to come in for communion on that date due to a COVID outbreak in the facility and also stated that documentation of when residents received communion was not maintained. The resident's participation in spiritual activities was minimal, with only one recorded instance from August to November 2024.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for insulin administration for a resident with diabetes, leading to a deficiency. The resident, admitted in November 2021, had a physician order dated October 2024 for 13 units of Humalog insulin before each meal, with instructions to hold the medication if the capillary blood glucose (CBG) level was less than 100. However, on November 1 and November 6, 2024, the resident's CBG levels were 123 and 110, respectively, and the insulin was incorrectly held by an LPN. The LPN mistakenly believed there were standing orders to hold insulin if the CBG level was at 150 or above and did not seek clarification from the resident's physician. This oversight was acknowledged by the Regional Nurse, who confirmed that physician orders should be followed as written.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for two residents, leading to deficiencies in care. Resident 8, admitted with a leg fracture, developed blisters on the left thigh due to a leg brace. These blisters were not accurately documented as Stage 2 pressure ulcers, as per CDC guidelines, and the incident report was incomplete, lacking input from the CNA who identified the condition. The wound nurse assessed the situation, but the documentation and classification of the blisters were not thorough or accurate. Resident 10, admitted with a Stage 4 pressure ulcer, was at high risk for developing additional ulcers due to factors like malnutrition and incontinence. During a wound care procedure, an LPN failed to maintain proper infection control practices. The LPN did not sanitize hands before donning gloves, used soiled gloves and scissors to handle clean dressings, and did not establish a clean field for the supplies. These actions compromised the sterility of the wound care process, as acknowledged by the LPN and a regional nurse.
Failure to Address Accident Hazards for Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to potential risks of injury. Resident 17, who was admitted with diagnoses including depression and severe obesity, exhibited hoarding behaviors that were not addressed in a timely manner. On October 27, 2024, Resident 17's bedside table fell on their left shin, causing a small abrasion. Despite an investigation by the Director of Nursing Services (DNS) on October 28, 2024, no predisposing environmental factors were identified, and the table was not evaluated until November 5, 2024. The hoarding issue was only acknowledged on November 7, 2024, indicating a delay in addressing the environmental hazard. Resident 37, admitted with chronic heart failure and dementia, had a care plan dated August 15, 2024, which required fall mats on both sides of their bed. However, observations from November 4 to November 8, 2024, revealed the absence of these fall mats. During an interview on November 8, 2024, the Resident Care Manager (LPN) was unaware of the missing fall mats, despite the care plan's requirements. This oversight in implementing the care plan further contributed to the unsafe environment for Resident 37.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to provide adequate care and services related to catheterization for a resident who was reviewed for catheterization. The resident, who was admitted with a diagnosis including a Stage 4 pressure ulcer, was observed with blood in the catheter tubing. The resident mentioned that blood in the tubing was normal after a catheter change. However, a review of the Treatment Administration Record (TAR) and Nursing Progress Notes for November 2024 revealed no documentation of catheter care, such as flushing, cleaning, or changing the catheter. Additionally, a staff member, identified as the Resident Care Manager-LPN, confirmed that there was no documentation in the resident's electronic record indicating that catheter care was provided.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, leading to potential risks of respiratory infections. Resident 17, who was admitted with diagnoses including depression and sleep apnea, used a CPAP machine. The facility's policy on equipment sanitation did not specify proper storage for respiratory equipment. Despite a physician's order to clean the CPAP equipment weekly, observations revealed that Resident 17's CPAP mask was improperly stored on a counter with a used tissue nearby. Staff confirmed that the CPAP equipment was stored uncovered with other personal items, acknowledging the inadequacy of the facility's policy and the improper storage practice. Similarly, Resident 28, admitted with respiratory failure and using a BiPAP machine, was observed to have their equipment stored unsanitarily on multiple occasions. The BiPAP machine was found on top of the nightstand, hanging over it, and on the bedrail, all in an unsanitary manner. Staff confirmed the improper storage of the BiPAP mask, which should have been stored in a bag. These observations highlight the facility's failure to ensure proper storage and sanitation of respiratory equipment, as required by their policies and physician orders.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with cerebral palsy who was dependent on staff for toileting. The resident, who was cognitively intact and able to understand others, reported that two caregivers made derogatory comments about the smell of their feces while providing toileting assistance. This incident was not documented in the resident's progress notes, indicating a lack of proper record-keeping regarding the event. The resident expressed embarrassment and reported the incident to the Activities Director, who then informed the facility administrator. The administrator confirmed awareness of the allegation and stated that the contract of the involved agency CNA was terminated due to the inappropriate comment. Despite the CNA's denial of making such comments, other staff members corroborated the resident's account, noting that the resident felt shamed and embarrassed. The incident highlights a failure in maintaining the dignity and respect of the resident, as required by regulatory standards.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Survey Agency (SSA) for a resident who was admitted with diagnoses including anxiety and depression. The incident occurred on August 31, 2024, which was a Saturday, and the following Monday was a holiday. The Facility Reported Incident (FRI) was sent to the SSA on Tuesday, September 3, 2024. During interviews, the Administrator was unable to recall when the FRI was sent, and the Director of Nursing Services (DNS) confirmed the timeline of events. This delay in reporting placed residents at risk for abuse.
Latest citations in Oregon
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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