Robison Jewish Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Oregon.
- Location
- 6125 Sw Boundary Street, Portland, Oregon 97221
- CMS Provider Number
- 385145
- Inspections on file
- 23
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Robison Jewish Health Center during CMS and state inspections, most recent first.
A resident was admitted with a documented Stage 2 pressure ulcer on the penis, but facility staff failed to identify, assess, treat, or monitor the wound as required. Despite multiple staff observing signs of injury and the resident expressing discomfort, there was no documentation or care planning for the ulcer. The condition worsened, resulting in severe tissue erosion and permanent loss of normal urinary function, as confirmed during a subsequent hospital stay.
The facility did not monitor for legionella in its water system as required by its infection control policy. Maintenance staff had not been trained or instructed to check for water borne pathogens, and the Maintenance Director was unaware of at-risk areas and confirmed no monitoring had occurred. An LPN-Infection Preventionist also had not been involved in identifying or monitoring areas at risk for legionella.
The facility did not have an effective system for receiving, tracking, or resolving grievances, as shown by missing and incomplete records, staff confusion about the grievance process, and residents' lack of understanding about how to file grievances. A resident with cancer and diabetes was unable to submit a grievance about a delayed transportation incident due to staff not providing the necessary form or follow-up. The administrator acknowledged the absence of a clear grievance tracking system, resulting in unresolved resident concerns.
Staff failed to keep medication and treatment carts locked and attended, leaving medications, including insulin and prescribed drugs for a resident with Parkinsonism and hypothyroidism, accessible to unauthorized personnel. Multiple carts were observed unlocked in different areas, and staff acknowledged the lapses in following medication security protocols.
Three residents with orders for PT and OT did not receive the frequency of therapy sessions prescribed by their physicians. One resident with chronic venous ulcers received no PT after an initial refusal, another with hemiplegia received only one PT session despite orders for twice-weekly therapy, and a third with lymphoma and diabetes received fewer PT and OT sessions than ordered. Staff and the administrator confirmed that insufficient therapy staffing led to the failure to provide services as ordered.
The facility did not consistently follow physician orders for medication administration and failed to assess and treat a change in a resident's skin condition. One resident received cancer medication late on multiple occasions, another missed and received late doses of antiseizure medication, and a third experienced ongoing itching and skin damage without proper assessment or physician notification. Staff interviews and documentation confirmed these deficiencies.
Two residents experienced deficiencies in their environment: one had personal belongings go missing after admission, with multiple staff failing to recover or replace the items, and another suffered significant sleep loss due to a neighbor's loud television, despite repeated complaints to staff. Staff interviews revealed a lack of training and ineffective interventions, resulting in unresolved issues with both property loss and excessive noise.
A resident with a hip fracture received PRN lorazepam for agitation and anxiety over several months, with administration records showing repeated use beyond the facility's 14-day policy limit. Staff confirmed that a physician did not re-evaluate or document a rationale for extending the PRN order as required.
The facility did not notify the state Long Term Care Ombudsman’s office when two residents—one with post-surgical cellulitis and another with Alzheimer’s and metabolic encephalopathy—were transferred to the hospital and subsequently discharged. Record reviews and staff interviews confirmed that required notifications were not made, and key staff were unaware of this requirement.
A resident with hemiplegia and finger contractures did not receive prescribed contracture management interventions, such as a contracture pillow or rolled washcloth, as ordered in the care plan. Staff interviews and observations revealed that these interventions were frequently missed, and no ongoing monitoring or range of motion (RA) exercises were documented or provided. Staff were unclear about their responsibilities, and the designated RA provider was unavailable, resulting in a lack of consistent care for the resident's contractures.
A resident requiring maximum assistance and use of a Hoyer lift for bathing did not receive scheduled showers on multiple occasions due to lack of staff and equipment availability. Staff and a family member confirmed that bathing was not provided as care planned, and documentation reflected missed showers without make-up baths.
Two residents identified as high fall risks did not receive or have documented neurological checks following falls, as required by facility protocol. Despite experiencing pain and being assessed by LPNs, there was no evidence in the clinical records that neuro checks were completed for either resident. Staff interviews and record reviews confirmed the lack of documentation and adherence to post-fall procedures.
A resident with cognitive impairment and left-sided weakness did not receive care in a dignified manner as per their care plan. A CNA was observed on video providing peri-care without proper cues, causing the resident to express pain. The CNA admitted the care was not performed according to the care plan, and the facility confirmed the lack of dignified care.
A resident with dementia and severe cognitive impairment, known for wandering and exit-seeking, fell and sustained serious injuries after exiting through an unarmed door alarm. The facility failed to implement necessary interventions or update the care plan despite the resident's increased wandering behavior.
The facility failed to maintain sanitary conditions for the ice machine, risking foodborne illness for residents. A powdery gray/green substance was found on the ice machine panel, with condensation dripping onto the ice. The Executive Chef acknowledged the issue, noting the machine was cleaned monthly but not included in weekly or daily cleaning schedules.
The facility failed to implement infection control practices for residents with catheters and those receiving wound care, as staff did not use gowns during high-contact care activities. Additionally, an LPN was observed administering medication without performing hand hygiene or using proper techniques, contrary to facility policy.
The facility failed to provide sufficient nursing staff to meet resident needs, leading to delays in care and increased safety risks. Staff and residents reported frequent understaffing, particularly on night shifts, resulting in unmet care needs and residents being left unattended. Despite reporting these issues, no changes were made to address the staffing deficiencies.
The facility failed to secure medication carts and manage expired drugs, as observed with unlocked and unattended carts and expired medications like Lantus insulin and influenza vaccines. Staff confirmed these lapses, and the DNS expected all carts and refrigerators to be locked and free of expired medications.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in fall prevention and medication management. One resident, at moderate fall risk, had a care plan intervention to keep the bed low, but it was not followed. Another resident on Apixaban, a high-risk medication, lacked proper monitoring in their care plan.
A resident with paroxysmal atrial fibrillation and other conditions was prescribed apixaban twice daily, but the facility failed to ensure consistent administration due to the resident's pattern of evening refusals. Despite extending the administration window, the refusals continued, and no further interventions were implemented, risking medical complications.
A resident with atrial fibrillation was not seen by a physician as required after admission, despite facility policy mandating visits every 30 days for the first 90 days and every 60 days thereafter. Staff confirmed the lack of documented physician visits since the resident's admission.
Two residents with moderately impaired cognition received expired COVID-19 vaccines due to an RN being distracted and failing to check expiration dates. The DNS expected expired vaccines to be disposed of promptly. Both residents were monitored for adverse side effects.
Failure to Identify, Assess, and Treat Stage 2 Penile Pressure Ulcer on Admission
Penalty
Summary
A resident was admitted to the facility with a documented Stage 2 pressure ulcer located on the left lateral meatus of the penis, as indicated in the admission and discharge paperwork from the previous facility. The documentation included specific orders to apply triple antibiotic ointment every shift with catheter care and to consult the Resident Care Manager if the wound worsened. However, upon admission, the facility failed to identify, assess, treat, or monitor the pressure ulcer. The resident's initial skin assessment, care plan, physician orders, and subsequent clinical records did not mention the presence of the pressure ulcer or any related treatment. Throughout the resident's stay, there was no documentation in the medical record or treatment administration records regarding the penile pressure ulcer. Multiple staff members, including CNAs and nurses, observed signs of injury such as bleeding, a tear, or a split on the penis during perineal or catheter care, but these observations were either not documented or not followed up with appropriate assessment and intervention. The resident also reported discomfort and requested to see a urologist, but there was no evidence that these concerns were addressed. Progress notes and care plans continued to omit any reference to the pressure ulcer or its management. The resident was eventually hospitalized, where it was discovered that the Foley catheter had caused significant erosion of the penile tissue, resulting in traumatic hypospadias and permanent loss of normal urinary function. Hospital records and interviews with hospital staff confirmed that the injury was consistent with prolonged catheter-related pressure and not an acute event. Facility leadership and care management staff were unaware of the pressure ulcer at the time of the survey, despite its documentation at the prior facility and multiple staff observations during the resident's stay.
Failure to Monitor for Legionella in Facility Water System
Penalty
Summary
The facility failed to monitor for legionella in its water system, as required by its Infection Prevention and Control Program policy. The policy indicated that a water management program was established, with control measures and testing protocols in place, and designated the Maintenance Director as the leader of the program. However, interviews revealed that maintenance technicians had not received training on water borne pathogens and were not instructed to monitor for legionella. The Maintenance Director was unaware of areas at risk for legionella development and confirmed that no monitoring had been performed for legionella or other water borne pathogens. Additionally, the LPN-Resident Care Manager/Infection Preventionist acknowledged understanding that legionella could develop in areas of standing water but had not participated in identifying at-risk areas or monitoring for legionella. No specific residents or their medical conditions were mentioned in the report.
Failure to Maintain Effective Grievance System and Staff Training
Penalty
Summary
The facility failed to maintain an effective system for receiving, tracking, and resolving resident and/or representative grievances, as required by its own grievance policy. Review of the facility's grievance binder revealed missing records for several months and incomplete documentation for others. During a Resident Council meeting, residents expressed confusion about how to file grievances and reported a lack of follow-up on submitted concerns. Staff interviews confirmed a lack of training and understanding regarding the grievance process, with some staff unaware of the location or purpose of grievance forms and others believing it was not their responsibility to assist residents with grievances. The Social Services staff acknowledged the absence of a consistent protocol for processing grievances and a tracking system to monitor resolution. One resident, admitted with diffuse large B-cell lymphoma and type 2 diabetes, experienced a significant delay in transportation after a medical appointment. The resident attempted to file a grievance regarding the 20-hour wait but did not receive the necessary form or follow-up from staff. The nurse involved admitted to not providing the grievance form and was unaware of its location. Other staff members also demonstrated confusion about the grievance process and the availability of forms, with some believing the forms were intended for employees rather than residents. The facility administrator confirmed that there was no clear system in place for tracking grievances or ensuring that concerns were addressed and resolved. The lack of a functioning grievance procedure and inadequate staff training placed residents at risk for unreported and unresolved grievances, as evidenced by incomplete records, staff confusion, and resident reports of unresolved issues.
Failure to Secure Medications and Treatment Carts
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were consistently secured and only accessible to authorized personnel, as required by facility policy. On multiple occasions, medication and treatment carts were observed unlocked and unattended in various areas, including the 300 Household, 700 Hall, and 900 Household. In one instance, a cup containing crushed medications mixed with a pudding-like substance, prepared for a resident with Parkinsonism and hypothyroidism, was left unattended on top of a medication cart. The nurse responsible for the cart was not present, and the cup was accessible to unauthorized staff. Staff later acknowledged that the medications should have been locked in the cart when unattended. Additionally, treatment carts containing insulin and medicated creams were found unlocked and unattended in both the 700 Hall and 300 Household. Staff admitted to leaving carts unlocked due to a lack of keys when agency staff were present. In another area, a medication cart was left unlocked, allowing staff to access its contents and use items from the cart without supervision. Facility leadership confirmed that all medications and carts should have been secured when not directly attended by authorized staff.
Failure to Provide Ordered Rehabilitation Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide occupational and physical therapy services as ordered for three of four sampled residents who required specialized rehabilitative services. According to the facility's own policy, such services are to be provided under physician orders by qualified personnel and are considered part of the facility's scope of services. However, documentation and staff interviews confirmed that residents did not receive the therapy sessions as prescribed. One resident with chronic venous hypertension and ulcers was evaluated for physical therapy four to five times per week but did not receive any sessions beyond an initial refusal, with no further attempts documented. Another resident with hemiplegia following a stroke was evaluated and ordered to receive physical therapy twice weekly but only received one session, with no explanation for the lack of further therapy. A third resident with diffuse large B-cell lymphoma and diabetes, who required assistance with mobility and was at risk for falls, was ordered to receive both physical and occupational therapy three to five times per week but only received two sessions of each per week, less than what was ordered. Staff interviews revealed that the primary reason for the missed therapy sessions was insufficient therapy staffing, which prevented the facility from meeting the frequency of therapy sessions indicated in the residents' evaluations and physician orders. The Director of Rehabilitation, who was responsible for scheduling, worked offsite and confirmed the lack of adequate staff to provide the required services. The facility administrator acknowledged the issue, stating that the census of residents needing therapy exceeded the available therapy staff.
Failure to Follow Physician Orders and Address Changes in Resident Condition
Penalty
Summary
The facility failed to follow physician orders and did not provide appropriate assessment and treatment for changes in residents' conditions, as evidenced by three separate cases. One resident with multiple myeloma was prescribed Venetoclax to be administered at specific times and in a specific manner, but the medication was given late on at least twenty-seven occasions. Staff acknowledged the delays, citing the resident's difficulty swallowing and the time required for administration, and stated that the medication was often given at the end of the medication pass. The resident and family members expressed concerns about the timeliness of medication administration, and staff confirmed that the medication was not consistently given within the required timeframe. Another resident with epilepsy and hemiplegia was prescribed Lacosamide to be administered twice daily at set times. Upon admission, the resident missed the first scheduled dose due to a script not being sent with the resident, and subsequent doses were administered late on multiple occasions. Staff interviews confirmed that antiseizure medications were expected to be prioritized and administered within a specific window, but this was not consistently achieved for this resident. A third resident with Parkinsonism reported persistent itching and suspected an allergic reaction to bedding, which resulted in frequent scratching and visible skin damage. The resident reported the issue to multiple CNAs, but the concern was not escalated to nursing staff or the physician. Observations confirmed the presence of scratch marks and bleeding, and staff interviews revealed that while some applied lotion, no further assessment or intervention was initiated, and the physician was not notified of the ongoing skin condition.
Failure to Protect Resident Property and Ensure Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain a homelike environment by not exercising reasonable care for the protection of residents' personal property and by not ensuring comfortable sound levels for residents. One resident, admitted with Parkinsonism and cognitively intact, reported missing personal items such as dress shirts and pants shortly after admission. The resident and a family member stated that the missing items were reported to multiple staff members, but no action was taken to recover or replace the items. Interviews with CNAs revealed a lack of training on handling missing property, and the Housekeeping/Laundry Supervisor acknowledged frequent mix-ups of resident belongings due to high staff turnover and agency staff usage. The Administrator stated that missing items should be reported and replaced within seven days, but was unaware of the specific case involving this resident. Another resident, admitted with gram-negative sepsis and anxiety disorder and with moderate cognitive impairment, experienced significant sleep disruption due to excessive noise from a neighboring resident's television. The neighbor, who also had moderate cognitive impairment and preferred watching television, played the television at a volume that was clearly audible in the affected resident's room, even with doors closed. The affected resident reported only sleeping about three hours per night and expressed distress over the situation. Multiple staff and a private caregiver confirmed ongoing complaints about the noise, and staff interventions such as providing headphones were only temporarily effective, as the neighbor eventually stopped using them and continued to play the television loudly. Staff interviews indicated that complaints about the noise were reported to CNAs and, in some cases, to nurses, but the issue persisted. The Administrator acknowledged awareness of the situation and stated that headphones had been provided, but was not fully aware of the extent of the problem at night. The facility's failure to address these issues resulted in a lack of a homelike environment, lost sleep, and unaddressed loss of personal property for the residents involved.
Failure to Re-Evaluate PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the use of PRN lorazepam. According to the facility's policy, PRN orders for psychotropic medications, excluding antipsychotics, must be limited to 14 days unless the attending physician or prescribing practitioner provides documentation with a rationale for extending the order and specifies a duration. A resident who was readmitted with a hip fracture had a physician order for lorazepam every four hours PRN for agitation and anxiety. Review of the resident's medication administration records showed that lorazepam was administered multiple times over several months, exceeding the 14-day limit without any documented physician rationale or re-evaluation for the continued use of the medication. During interviews, staff confirmed that the required physician re-evaluation did not occur at the end of the 14-day period, and acknowledged that this step should have been completed.
Failure to Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman’s (LTCO) office regarding the transfer or discharge of two residents who were hospitalized and subsequently discharged. For one resident admitted with aftercare following surgery and cellulitis, documentation showed a transfer to the hospital for nausea and vomiting, but there was no record of LTCO notification. For another resident with Alzheimer’s Disease and metabolic encephalopathy, records indicated a hospital transfer due to wound complications and subsequent discharge from the facility, again without any evidence of LTCO notification. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed that both were unaware of the requirement to notify the LTCO’s office for resident transfers and discharges. The lack of notification was confirmed through both record review and staff statements, indicating a systemic failure to ensure required notifications were made for residents experiencing significant changes in their care setting.
Failure to Provide Contracture Management and Range of Motion Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for a resident with hemiplegia and existing contractures in the fingers of one hand. The resident's care plan and physician orders specified the use of a contracture pillow or a rolled washcloth during the day to manage contractures, but observations over several days revealed that these interventions were not consistently implemented. The resident was repeatedly observed without the prescribed contracture pillow or rolled washcloth in place, and staff interviews confirmed that these items were often overlooked or not provided as ordered. Further, there was no evidence in the clinical record of comprehensive assessment, ongoing monitoring, or range of motion (RA) exercises being completed for the resident. Multiple staff members, including CNAs, LPNs, and therapy staff, indicated confusion or lack of knowledge regarding responsibility for implementing the contracture interventions. Some staff stated that RA services were not being provided, and others were unaware of the resident's needs or the existence of a contracture pillow. The designated staff member responsible for RA was on leave, and no alternative arrangements were made, resulting in a lack of consistent care to address the resident's contractures.
Failure to Provide Bathing Assistance as Care Planned
Penalty
Summary
A resident with a history of stroke, admitted in May 2025, was care planned to require maximum assistance with a Hoyer lift and was dependent on staff for showering twice weekly and as needed. Review of task charting for June, July, and August 2025 showed that on multiple occasions, bathing was documented as 'not applicable' by several CNAs, with no evidence that make-up showers were provided. Staff interviews confirmed that bathing was not completed on these dates due to lack of available staff to assist with the Hoyer lift or unavailability of the lift itself. A family member reported that the resident was not provided assistance with showers as required. Staff, including CNAs and an RN care manager, acknowledged that the resident was not bathed or showered on the documented dates, citing ongoing staffing difficulties. The administrator and director of nursing services confirmed that residents should be bathed according to their care plans and as needed.
Failure to Complete and Document Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide treatment and care according to professional standards of practice by not completing and documenting neurological checks (neuro checks) after falls for two residents identified as high fall risks. According to the facility's fall procedure, residents who experience a fall are to be placed on neuro checks for 72 hours, with each check documented in the Neuro Check Binder. For one resident with a history of joint replacement surgery and self-care deficits, an unwitnessed fall occurred while attempting to self-transfer. Although the resident reported back pain and received pain medication, there was no documentation that neuro checks were performed or recorded following the fall. A subsequent progress note indicated that the responsible LPN failed to complete the required neuro assessments. Another resident, admitted with a right femur fracture and dementia, also experienced a fall and was reportedly placed on neuro checks after complaining of significant pain. However, a review of the clinical record revealed no evidence that neuro check assessments were completed or documented. Staff interviews confirmed that neuro checks were not always performed due to time constraints, and the medical records staff verified the absence of documentation for both residents. The administrator and director of nursing services acknowledged that the post-fall neuro check procedures were not followed for these residents.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with cognitive impairment and left-sided weakness. The resident, admitted in October 2021, had a care plan that required non-rushed guided care and continuous face-to-face verbal communication during peri-care. However, a video recorded incident showed the CNA providing care in a manner that was not in accordance with the care plan. The CNA was observed grabbing the resident's groin without cues or prompting, causing the resident to respond verbally in a painful manner. The facility's investigation concluded that the resident did not show any adverse behaviors or injuries as a result of the incident. During a review of the video, the CNA was seen expressing frustration and grabbing the resident's genitals without proper cueing, which prompted the resident to yell in pain. The CNA denied providing inappropriate care but confirmed that the care was not performed according to the resident's care plan. The facility administrator confirmed that the care was not performed in a dignified manner as per the care plan.
Failure to Implement Fall Prevention Interventions for Wandering Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a fall for a resident with a history of wandering and exit-seeking behavior. The resident, who was admitted with dementia and anxiety, was noted to have severe cognitive impairment and a pattern of wandering. Despite these known behaviors, the facility did not have exit-seeking or wandering interventions in place prior to the resident's fall. On the day of the incident, the resident exited the unit through a side door with unarmed alarms, resulting in a fall down the stairs with a walker. The fall led to serious injuries, including a head hematoma, gluteal hematoma, multiple rib fractures, and skin avulsions, requiring emergency medical services and hospitalization. Interviews with staff revealed that the door alarm was not reset by an unknown staff member, allowing the resident to exit unnoticed. Staff acknowledged the resident's increased wandering behavior prior to the fall, but no new interventions or updates to the care plan were implemented to address these changes.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to ensure the ice machine was cleaned adequately to maintain sanitary conditions, which placed residents at risk of foodborne illness. During an observation, a powdery gray/green substance was found accumulated in the grooves of the panel directly above the ice supply in the kitchen's ice machine. Condensation was observed dripping across the panel's grooves and onto the ice supply. The Executive Chef/Director of Dining Services acknowledged the presence of the substance and confirmed that it should not be present and should be cleaned. A review of the Ice Machine Cleaning Log indicated that the machine was cleaned on a monthly basis, but the task was not included in the kitchen's weekly Deep Cleaning Schedule or Daily Cleaning Schedule. The Executive Chef/Director of Dining Services stated that the ice machine was expected to be cleaned to prevent contamination of the ice provided to residents.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices for 18 residents and one staff member, placing residents at risk for infection. Observations revealed that enhanced barrier precautions, such as the use of gowns and gloves during high-contact resident care activities, were not implemented for residents with urinary catheters or those receiving wound care. Despite the CDC guidelines specifying the need for such precautions, staff only wore gloves and not gowns during care. The facility's Infection Preventionist acknowledged that enhanced barrier precautions should have been in place for residents with catheters or those receiving wound care. Additionally, the facility's medication administration practices were found to be lacking in infection control measures. During a medication administration observation, an LPN was seen using her fingers to retrieve a pill and place it in a resident's mouth without performing hand hygiene before or after the task. The LPN admitted to not following the facility's policy, which requires hand hygiene before and after medication administration and prohibits touching medications with bare hands. The facility's DNS confirmed the expectation for hand hygiene and proper handling of medications.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by multiple staff and resident reports. The facility had a census of 39 residents, with many requiring extensive assistance for daily activities such as transfers, bathing, toileting, and dressing. Staff interviews revealed that the facility often operated with inadequate staffing levels, particularly on the night shift, which led to residents waiting for assistance and increased risks of falls and elopement. Staff members reported that they were frequently unable to provide the necessary two-person assistance for transfers and care, leaving residents unattended and compromising their safety. The facility's staffing policy, revised in 2007, indicated that adequate staffing should be provided to meet residents' needs. However, staff members, including CNAs and LPNs, reported that the facility was often short-staffed, especially during the night shift. This shortage was exacerbated by the facility's decision to stop using agency staff and the lack of awareness of specific staffing requirements for bariatric residents. As a result, staff were unable to provide timely care, and residents experienced delays in having their needs met, such as waiting for call lights to be answered and for assistance with transfers and personal care. Residents and staff expressed concerns about the safety and supervision of residents, particularly in the 400 house, where residents with high acuity needs resided. Reports indicated that residents were left unattended, leading to incidents such as a resident wandering into another's room unsupervised. Staff were also burdened with additional non-care tasks due to staff reductions in other departments, further straining their ability to provide adequate care. Despite reporting these issues to the Director of Nursing Services and the Staffing Coordinator, no changes were made to address the staffing deficiencies.
Medication Security and Expiration Issues
Penalty
Summary
The facility failed to ensure the security and proper management of drugs and biologicals, as evidenced by several observations of unlocked and unattended medication carts and expired medications. On multiple occasions, medication carts on different halls were found unlocked and unattended, which was confirmed by staff members. Specifically, on the [NAME] Hall, a treatment cart was left unlocked and unattended by an RN. Similarly, two medication carts on the 200 hall were also found in the same condition, which was acknowledged by the RN on duty. Additionally, the facility did not adequately manage the expiration of medications. An LPN discovered expired Lantus insulin in a medication cart, and further inspection revealed that the emergency medication refrigerator was unlocked. Expired medications, including fish oil supplements and influenza vaccines, were found in the medication storage room and confirmed by staff to be past their expiration dates. The DNS expressed that the expectation was for all carts and refrigerators to be locked and free of expired medications.
Deficiencies in Care Plan Implementation for Fall Prevention and Medication Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in fall prevention and medication management. Resident 3, admitted with congestive heart failure, was identified as being at moderate risk for falls. Despite a care plan intervention to keep the bed in a low position to minimize fall risk, observations revealed the bed was at a normal height. Staff, including a CNA and RNCM, were unaware or did not implement the fall prevention strategies outlined in the care plan, increasing the resident's risk of falls. Resident 8, admitted with a pulmonary embolism and acute cor pulmonale, was prescribed Apixaban, a high-risk anticoagulant medication. However, the resident's care plan did not include monitoring for this high-risk medication. The DNS confirmed that the care plan should have included monitoring for high-risk medications like anticoagulants, but it did not, indicating a failure in medication management for Resident 8.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for a resident diagnosed with paroxysmal atrial fibrillation, hemiplegia due to a stroke, and high blood pressure. The resident was prescribed 5 mg of apixaban to be administered twice daily to prevent blood clotting. However, the Medication Administration Records (MARs) for June and July 2024 showed multiple instances where the resident refused the medication, particularly in the evenings. Despite the refusals being documented, there was no evidence of effective interventions to ensure the resident received the prescribed medication. Interviews with facility staff revealed that the resident had a known pattern of refusing medications in the evenings, especially after going to bed. Staff attempted to address this by extending the medication administration window from two hours to four hours in the evening. However, this intervention did not resolve the issue, as the pattern of refusals persisted. The facility did not implement additional strategies to address the ongoing refusals, which placed the resident at risk for medical complications due to the lack of consistent medication administration.
Failure to Ensure Regular Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. This deficiency was identified for one of the five sampled residents reviewed for medications. The resident in question was admitted to the facility in July 2023 with a diagnosis of atrial fibrillation, a condition characterized by an irregular and often rapid heart rate. A review of the resident's health record revealed no documented physician visits since admission. Interviews with facility staff confirmed that the resident had not been seen by their primary care physician since admission, despite the facility's policy requiring regular physician visits within the specified timeframes.
Expired COVID-19 Vaccines Administered to Residents
Penalty
Summary
The facility failed to ensure that expired COVID-19 vaccines were not administered to two residents, leading to a significant medication error. Resident 19, who was admitted with diagnoses including congestive heart failure and had moderately impaired cognition, received an expired COVID-19 vaccine. This occurred because Staff 8, an RN, was distracted and did not check the expiration date before administering the vaccine. Similarly, Resident 36, admitted with a fracture of the left femur and also with moderately impaired cognition, received an expired COVID-19 vaccine under the same circumstances. Staff 8 admitted to being distracted and failing to verify the expiration date. Staff 2, the DNS, stated that it was expected that expired vaccines would be disposed of promptly. Both residents were placed on alert charting and monitored for adverse side effects following the administration of the expired vaccines.
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A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
The facility failed to maintain an effective pest control program, resulting in an ongoing roach infestation documented over several months. The contracted pest control provider serviced the building only once per month and reported continued evidence of roaches, while indicating that more frequent applications were needed. The Administrator acknowledged persistent roach problems throughout the facility, and several CNAs reported seeing roaches, with some noting that sightings were not consistently documented and one CNA unaware of the pest control log. This lack of consistent reporting and insufficient pest control measures placed residents at risk for exposure to household pests and increased health risks.
The facility failed to maintain a clean and homelike environment when a cognitively intact resident with anxiety reported that their room had not been cleaned for several days, and surveyors observed dirty floors, debris, dark stains in the toilet bowl, and a urine odor in the bathroom. The shared bathroom and multiple shower rooms were also found with dark substances on toilet surfaces, unclean baseboards, and unkept conditions. Only one housekeeping staff member, the Director of Housekeeping, was working at the time of the survey, and leadership acknowledged an expectation that resident areas be clean.
A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
The facility failed to provide ordered PT, OT, and SLP services and to complete timely therapy evaluations for several residents. One resident with a stroke and fall history was ordered PT, OT, and SLP; PT was delivered less frequently than prescribed, SLP treatments were not documented after being ordered, and OT evaluation occurred weeks late with only limited OT sessions provided. Another resident with diabetes and protein-calorie malnutrition was discharged from the hospital with a mechanical soft diet and SLP orders but did not receive an SLP assessment for over two weeks and remained on modified textures until then. A third resident with muscle weakness had an OT order but did not receive an OT evaluation for more than two months and reported never receiving OT, which was corroborated by multiple CNAs and an RN. A fourth resident with an anoxic brain injury and femur fracture had an orthopedic PT order that was never acknowledged or communicated to therapy, and no PT was provided. Staff, including the Administrator and rehab leadership, confirmed these lapses and delays in therapy services and evaluations.
A resident admitted with spinal stenosis, chronic back pain, anxiety, panic disorder, and opioid dependence had a PRN hydrocodone-acetaminophen order entered on admission, but the medication was not available for use until the early morning of the next day. The admitting LPN reportedly told the resident and a complainant that the pain medication would arrive within a few hours, yet the prescription was not sent to the pharmacy, and there was no documentation of follow-up or explanation for the delay. During the night, the resident repeatedly requested pain medication, reported significant pain to a CNA and to a complainant by phone, and an RN later confirmed the drug was unavailable until a new prescription and access to backup stock were obtained.
A significant med error occurred when an LPN gave a resident 12 meds intended for another resident instead of the resident’s scheduled morning meds. The resident, who was cognitively intact and had HTN, reported feeling weak after taking the pills, and staff later found very low BP. The resident was sent to the hospital and diagnosed with bradycardia, hypotension, and transient circulatory shock secondary to an unintentional medication overdose, requiring ICU care and vasopressor support.
Unsecured Medication and Treatment Carts: Medication and treatment carts on the 200 Hall were observed unlocked on multiple occasions while staff were away from them or out of sight. An RN, an LPN, and another RN each confirmed the carts were unlocked, and residents’ prescribed medications and a treatment cart containing insulin and needles were inside. Staff stated carts were expected to be locked whenever unattended.
Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Maintain Effective Pest Control for Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing roach activity documented over several months and corroborated by staff and the contracted pest control provider. On 4/22/26, the contracted pest control technician (Witness 9) was observed placing roach traps and reported that, per contract, he only serviced the facility once per month. He stated he had seen evidence of roaches for months, though not rodents, and indicated that the facility really needed pest control services twice per month to eradicate the roaches. Review of the Pest Control Log on 4/22/26 showed roach sightings reported from 10/2025 through 4/2026. The Administrator (Staff 1) acknowledged ongoing roach concerns throughout the facility and stated he had asked the pest control provider during past and recent monthly visits for more frequent service to control pests, especially roaches. Multiple CNAs (Staff 43, Staff 44, and Staff 27) reported seeing roaches in the facility, with Staff 43 and Staff 44 stating that sightings were not always written or reported in the Pest Control Log, and Staff 27 stating she was unaware of the Pest Control Log for reporting pest sightings. On 4/27/26, the Administrator confirmed the ongoing roach issue and stated he expected the facility to be pest free. This deficiency placed residents at risk for exposure to household pests and increased health risks, as the facility did not ensure that pest sightings were consistently documented or that pest control services were provided at a frequency sufficient to address the persistent roach problem.
Failure to Maintain Clean and Homelike Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when resident rooms, shared bathrooms, and shower rooms were observed to be unclean and poorly maintained. Resident 41, admitted in 2025 with diagnoses including anxiety and assessed as cognitively intact on a 1/28/26 Quarterly MDS, reported that the room was not cleaned regularly and had not been cleaned since 4/17/26, attributing this to the facility often being short staffed. On 4/19/26, surveyors observed that the floor in the resident’s room appeared unwashed with dark spots around the toilet and throughout the bathroom, and later that day the room had a dirty floor with debris, dark stains in the toilet bowl, and a bathroom that smelled of urine. The shared bathroom for the room was also observed with dark stains in the toilet bowl. On 4/19/26, Staff 19, the Director of Housekeeping, was observed to be the only housekeeping staff working in the facility and confirmed he was the only person working in housekeeping when the survey team entered. During a subsequent facility walkthrough on 4/24/26 with Staff 19 and Staff 20, the Regional Director of Housekeeping, they confirmed the presence of a dark substance on the toilet seat, handle, and tank in the shared bathroom, as well as unclean floor baseboards in the room. They also confirmed that resident shower rooms on all three halls appeared unclean and unkept, with items left in the rooms. The Administrator later acknowledged during a walkthrough that he expected residents’ rooms and areas to be clean.
Failure to Monitor Skin, Administer Insulin Timely, and Provide Ordered Anxiolytic Medication
Penalty
Summary
The deficiency involves failures to provide treatment and care according to physician orders and residents’ needs in the areas of skin monitoring, insulin administration, and psychotropic medication management for three residents. For one resident with diabetes and a history of bilateral lower extremity and right foot wounds, the wound care provider documented that all wounds had healed and recommended ongoing monitoring for reopening or new wounds. The resident’s care plans and physician orders required weekly diabetic foot checks, weekly head‑to‑toe skin inspections, daily inspection of the feet during ADLs, and notification of the provider and resident care manager of any new skin issues or refusals. Documentation on the TAR showed that weekly diabetic foot checks and skin inspections were marked as completed with no issues, and a quarterly nursing evaluation indicated no skin integrity concerns, despite the resident’s documented routine refusals of care. During observation, the resident was found wearing pants, thick socks, and heavy boots, and reported having trouble with socks and leg pain for a couple of months. When the resident pulled up a pant leg, the surveyor observed a dark red sock covered in flaked skin, bright red and raw‑appearing skin with a large indent at the ankle, a malodorous odor, and a dirty, blood‑tinged bandage stuck to the skin under the sock. The resident’s socks appeared dirty and covered in flaked skin, and the resident’s speech was disorganized. Staff interviews revealed that some nurses did not complete skin checks, a CNA had never visualized this resident’s legs or feet due to refusals to shower or remove shoes, and the LPN who documented a head‑to‑toe skin inspection stated she had never actually completed one for this resident and did not recall the documented assessment. Another LPN stated she had never assessed the resident’s feet and that her TAR entries reflected refusals, but she had not notified the provider. The resident care manager and DNS acknowledged uncertainty about when to notify the provider and confirmed the provider had not been notified of repeated refusals of skin inspections or diabetic foot checks. For a second resident with diabetes requiring hemodialysis, physician orders required scheduled insulin aspart doses with meals and additional sliding‑scale insulin before meals and at bedtime at specific times. Review of the diabetic administration record showed multiple instances where both scheduled and sliding‑scale insulin doses were administered significantly later than the ordered times, with no documentation in the clinical record explaining the delays. The resident reported that insulin was often not administered timely, especially at bedtime, and described being a brittle diabetic for whom timely insulin was very important. An RN confirmed that the resident’s blood sugars dropped quickly and that the resident had reported late nighttime insulin administration, and stated that night shift nurses could become busy and unable to give insulin on time. The resident care manager confirmed the late administrations, stated that nurses were required to write progress notes when insulin was given late, and acknowledged that no such notes were present for the identified dates. For a third resident admitted with spinal stenosis, anxiety disorder, panic disorder, and opioid dependence, admission orders included lorazepam 1 mg tablets scheduled twice daily and an additional PRN evening dose for generalized anxiety disorder. The MAR showed that the scheduled lorazepam doses were not administered at the ordered morning and midday times on the day after admission, and that the PRN evening dose was instead administered in the morning, contrary to the order. The admitting LPN did not recall the resident or any issues with lorazepam delivery and had no documentation clarifying whether or when the prescription was sent to the pharmacy. The complainant reported that the admitting nurse had told the resident the lorazepam would arrive within a few hours, but the resident later called in distress stating the medication was not available; when the complainant contacted the facility, they were told the prescription had not been sent to the pharmacy. A CNA stated the resident was agitated the night of admission, requested anti‑anxiety medication several times, and called the complainant twice about not receiving medication. The night RN confirmed the resident appeared agitated, that the lorazepam order had not been sent to the pharmacy, that the medication was not available, and that a pull from the backup supply was denied due to a dose mismatch, resulting in the resident not receiving lorazepam the night of admission or the scheduled doses the following day, with no documented follow‑up on the delay in the medical record.
Failure to Provide Ordered PT, OT, and SLP Services and Timely Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered for multiple residents. One resident admitted with a stroke and history of falls had physician orders for PT, OT, and SLP evaluations and treatments as indicated. PT assessed this resident for therapy five times per week for a defined certification period, but documentation showed PT was only provided four times per week during several weeks. SLP initially did not recommend services, but after a subsequent assessment on 1/19/26, the resident was ordered SLP twice weekly for 60 days, with no documentation of any SLP treatments after that date. OT did not evaluate this resident until 42 days after admission, and although OT determined a need for services five days per week for 60 days, the resident received OT on only a limited number of dates before discharge. The Administrator confirmed that therapy services were not provided as prescribed and that evaluations were not completed within the expected timeframe. Another resident, with diagnoses including diabetes and mild protein-calorie malnutrition, was transferred from the hospital with orders for a mechanical soft diet and SLP evaluation and treatment. The SLP assessment did not occur until 17 days after readmission, during which time the resident continued on mechanical soft diet textures. The resident reported it took about a month to get off puree foods and stated they were told the facility needed to hire more SLP staff before an assessment could be completed. The Regional Director of Rehabilitation and the Administrator both confirmed the delay in SLP assessment and were unable to explain why the evaluation was not completed sooner, despite existing orders for SLP evaluation and treatment. A third resident admitted with muscle weakness had physician orders dated 2/12/26 for OT evaluation and treatment, but the OT evaluation was not completed until 4/20/26. The admission MDS indicated the resident had not received any therapy services in the seven days prior to that assessment. The resident stated they had not received OT and were interested in therapy to help them leave the facility. Multiple CNAs and an RN reported they had never observed this resident working with therapy since admission. The Rehabilitation Director acknowledged the OT evaluation was not timely and cited difficulty maintaining Certified Occupational Therapy Assistants. In a fourth case, another resident with anoxic brain injury and a right femur fracture had an orthopedic order for PT, but the clinical record contained no evidence that the PT order was acknowledged, clarified, or communicated to the therapy department, and the resident did not receive PT. An RN case manager stated the order must have been missed and confirmed that therapy was not provided.
Failure to Ensure Timely Availability of Ordered PRN Opioid for New Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a cognitively intact resident admitted with spinal stenosis, dorsalgia, anxiety disorder, panic disorder, and opioid dependence. On admission, the resident had an order for hydrocodone-acetaminophen 10 mg-325 mg every four hours as needed for pain, entered on the Medication Administration Record on the day of admission. However, the first documented administration of this medication did not occur until the early morning of the following day. During this period, the ordered hydrocodone-acetaminophen was not available in the facility because the prescription had not been sent to the pharmacy, and there was no documentation by the admitting nurse explaining the delay or any follow-up on obtaining the medication. According to interviews, the admitting nurse reportedly told the resident and a complainant that the hydrocodone-acetaminophen would arrive within a few hours of admission, but by late that night the resident was calling the complainant in distress, reporting pain and lack of access to the medication. A CNA stated the resident was in pain, agitated, and repeatedly requested pain medication, and that these requests were reported to the nurse. An RN on the night shift confirmed receiving a call from the complainant about the resident’s pain and discovered that the prescription had not been sent to the pharmacy, prompting a request to the on-call provider and use of the backup supply before the first dose was finally administered. Resident care managers later stated that, given the resident’s condition and admission from home without a hard copy prescription, the admitting nurse should have obtained a STAT prescription and documented diligent follow-up, but the record contained no such documentation and the medication was not readily available when requested.
Medication Error Resulted in Hospitalization for Hypotension and Shock
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident’s medications to a cognitively intact resident with diagnoses including post-surgical digestive system aftercare and essential hypertension. The resident’s medication administration record showed scheduled morning medications including amiodarone, losartan, and metoprolol, and the resident stated that on the morning of the error the nurse gave more pills than usual and told the resident this was the correct amount. The resident reported feeling very weak after taking the medications. The nurse later stated he accidentally gave the resident 12 medications intended for another resident and did not follow the five rights of medication administration, explaining that he was distracted and unfamiliar with the area. Staff observed the resident to be unusually confused that morning, and the resident’s blood pressure was found to be very low after the error was recognized. The resident was sent to the hospital, where records showed bradycardia, hypotension, and transient circulatory shock secondary to unintentional medication overdose, requiring ICU admission and vasopressor support.
Unsecured Medication and Treatment Carts
Penalty
Summary
Medication and treatment carts on the 200 Hall were observed unsecured during multiple survey observations, contrary to the facility’s Security of Medication Cart policy, which required carts to be locked during medication pass, before a nurse entered a resident’s room, and whenever the cart was out of the nurse’s view. On 4/20/26, an RN was observed standing next to an unlocked medication cart and then walking away from it before locking it; she stated she did not have the key because she was not in charge of the cart and could not find the person responsible for it, while confirming residents’ prescribed medications were in the cart. On 4/21/26, an unlocked treatment cart was observed in the 200 Hall while an LPN and another staff member were in the bistro area and not within sight of the cart; the LPN confirmed the cart was unlocked and stated the expectation was to lock medication and treatment carts whenever walking away from them. On 4/23/26, another unlocked medication cart was observed in the 200 Hall, and an RN confirmed it was unlocked and that residents’ prescribed medications were inside; she stated she was distracted and more accustomed to working night shift. Later that day, the DNS stated staff were expected to lock medication and treatment carts whenever away from them for safety purposes.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during wound care for Resident 7, who was admitted in 3/2026 with a diagnosis of diabetes and was being treated for a pressure ulcer. During observation on 4/21/26 at 11:14 AM, an LPN removed the resident’s old pressure ulcer dressing and adjusted the resident’s incontinent brief, then was stopped by the surveyor before cleaning the pressure ulcer. The LPN stated he should have changed gloves when moving from a dirty task to a clean task, then removed the gloves and was stopped again before putting on clean gloves to ensure hand hygiene was performed. The facility’s Standard Precautions policy stated hand hygiene was to be performed when hands were not visibly soiled and gloves were to be changed as necessary during care to prevent cross-contamination when moving from a dirty site to a clean site. On 4/24/26, the DNS stated staff were to follow infection control standards including changing gloves as needed and performing hand hygiene when gloves were removed.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
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