Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oregon Living And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its own policy requiring at least once‑per‑shift assessments, including full vital signs and respiratory checks, for residents receiving skilled services. An LPN and the DON both stated that skilled residents should have daily or every‑24‑hour vitals and, when on oxygen, additional O2 saturation checks, but chart reviews for three skilled residents showed infrequent and inconsistent documentation of blood pressure, pulse, respirations, temperature, and oxygen saturation over multiple days. Two residents also reported that their blood pressure and pulse were only checked occasionally, supporting the documented gaps in required monitoring.
A resident with pelvic and rib fractures and fragile respiratory status experienced ongoing, poorly controlled pain because hydrocodone-acetaminophen orders were repeatedly entered and maintained incorrectly. Hospital and orthopedic instructions specified 10/325 mg every 4 hours PRN for moderate pain, but the resident initially received 5/325 mg every 4 hours, then 10/325 mg every 6 hours, and the MAR was never corrected to the every-4-hour regimen. Pain assessments and provider notes documented frequent to almost constant pain interfering with sleep and daily activities, with pain scores up to 9/10. Staff recognized the discrepancy, faxed the physician for clarification, but did not follow up when no response was received, leaving the inaccurate order in place and the resident’s pain inadequately managed.
The facility failed to accurately reconcile and control its controlled substances, leading to unaccounted medication for a resident. Surveyors found multiple mathematical and documentation errors on the controlled substance card-sheet count (CCS), including incorrect totals after additions/removals, unexplained changes in counts across shifts, missing CCS sheets, and a decrease in the number of controlled substance bottles without documented removal or waste. The DON acknowledged the CCS errors, reported that a nurse’s initials had been forged on a CCS sheet, and confirmed the facility could not determine when a resident’s hydrocodone-acetaminophen went missing or who took it. The only written guidance was a brief controlled substance section within the Medication Administration policy, which did not address wasting, witnessing waste, storage, handling of completed CCS sheets, responsibility for maintaining them, or reconciliation between CCS sheets.
A resident with dementia and no documented pain received a pharmacy delivery of hydrocodone-acetaminophen, but the facility could not produce the corresponding February controlled substance count sheets or the CCS for the period after delivery, and there was no record of destruction of the medication. MARs showed almost no administration of the PRN narcotic despite consistent pain scores of 0/10, and staff, including an LPN and CNAs, reported rarely or never seeing the resident in pain or needing to give the PRN narcotic. An LPN who stated she received and logged the narcotic later disputed initials attributed to her on a CCS entry, alleging they were not hers and that she had left work earlier than the documented time, suggesting a possible forgery. The DON acknowledged that the facility could not account for the resident’s hydrocodone-acetaminophen, and the Administrator recognized the missing records, documentation gaps, and potential forgery in the context of the facility’s abuse prevention policy on misappropriation of resident property.
A facility failed to report an allegation of misappropriation of a resident’s hydrocodone-acetaminophen to the State Agency and local law enforcement as required by its Abuse Prevention Program. After a narcotic count discrepancy was identified, facility staff attributed it to documentation errors such as missing PRN sign-outs and incomplete narcotic logs, and concluded the concern was unsubstantiated. The resident’s MAR showed only one documented PRN dose despite a standing PRN order and a pharmacy delivery of 60 tablets, which the DON later stated could not be accounted for and for which controlled substance count sheets were missing. The Administrator later acknowledged the allegation should have been reported but confirmed it was not.
A cognitively impaired, wandering resident with dementia and a history of entering other residents’ beds was care planned with diversional and structured activity interventions but was left unsupervised long enough to leave the common area and enter a male resident’s room. An activity aide assigned to remain in the common area did not engage the resident in 1:1 activities and could not state when the resident left or whether she herself had left the area. Staff later found the fully dressed female resident lying in bed with an unclothed male resident, with both appearing calm and showing no signs of injury, while the male resident later reported that the woman had come into his room, sat on his bed, and would not leave despite his requests.
Failure to send dermatology referrals for residents with ongoing rashes. Multiple residents had physician orders for derm referrals due to persistent rashes that were not improving with treatment, yet the facility lacked fax confirmations for several referrals and appointments had not been scheduled for some residents. Staff reported multiple residents remained itchy and the cause of the rashes was still unknown.
A resident with a history of dysphagia and cognitive impairment was served diced ham instead of ground ham, contrary to dietary recommendations for a mechanical soft diet. This led to a choking episode requiring a CNA to perform the Heimlich maneuver. Staff interviews revealed confusion about proper food texture, and facility policies and spreadsheets specifying ground ham were not followed.
Resident Refrigerator Temperature Out of Compliance: The resident food and drink refrigerator was observed at 44 degrees Fahrenheit and the temperature log showed repeated readings of 44 to 48 degrees Fahrenheit over several days. The DON stated night shift nurses checked the refrigerator, but the posted form did not give clear directions on the acceptable temperature or what to do if it was out of range. The facility policy required resident refrigerators to stay at 41 degrees Fahrenheit or below.
Unsafe hot liquid service and failure to use gait belt during transfer: The facility served coffee and hot water at temperatures residents said were too hot to drink, while the DON and RDO stated there was no hot liquid assessment process and the machine was set to 205 degrees. The facility also failed to use a gait belt when transferring a high-fall-risk resident with weakness and a history of falls, despite physician orders and the care plan requiring a gait belt for all transfers.
An LTC facility failed to maintain infection control during incontinence care, medication administration, and equipment cleaning. CNAs did not change gloves when moving from dirty to clean tasks while providing peri care to a resident who was incontinent of bowel and bladder, an LPN did not perform hand hygiene after removing gloves while giving eye drops, and the same LPN did not disinfect a glucometer or blood pressure wrist cuff before returning them to the med cart. The DON confirmed hand hygiene and equipment disinfection requirements, and facility policies required these infection control steps.
Failure to Report Allegations of Misappropriation: The facility did not report allegations of missing resident money to the local health department or local authorities. A resident’s sister-in-law reported $180 missing, the resident later stated she believed someone took it, and staff described the resident as alert, oriented, and consistently carrying her purse. The DON/Administrator acknowledged the incident was not reported because the resident and family did not want to proceed and thought the money might be found.
A resident on hospice was found in bed with an air mattress that was not turned on, even though staff confirmed it had been provided by hospice to help prevent pressure injury. An LPN later turned the mattress on, but the ordered setting was not obtained until afterward, and the hospice note and care plan did not include the mattress details or setting.
Pressure ulcer care was deficient when staff failed to complete weekly wound assessments for a resident with an existing stage 2 ulcer and did not identify a new open pressure ulcer during survey observation. A second resident with a deep tissue injury to the heel did not have a specific care plan for the wound, and the care plan lacked heel offloading interventions even though wound notes directed heel protection and staff said CNA charting pulls interventions from the care plan.
A resident with multiple neurologic and vascular diagnoses had highly inconsistent weight entries, including a large gain followed by a large loss, but there was no documentation that the weights were rechecked for confirmation. The RD noted significant recent weight loss and recommended weekly weights, but the resident had no physician order for weekly weights and was not on the weekly weight list; staff stated RD recommendations were expected to be sent for orders and entered into the chart, but this did not occur.
A beautician at an LTC facility used inappropriate language while providing hair care to a resident with severe cognitive impairment, asking if the resident likes to 'b***h a lot.' The incident was overheard, leading to the beautician's removal and an investigation. The resident, who has dementia, did not recall the incident. The facility's policy emphasizes respect and dignity, which was not upheld in this case.
A resident requiring IV flushes did not receive them on multiple occasions due to the unavailability of RNs, as LPNs were not permitted to perform this task. The facility lacked a specific policy for peripheral IV maintenance, leading to missed flushes primarily during night shifts when an RN called off.
The facility failed to provide a homelike environment by not replacing a broken clock in the dining room, despite repeated requests from residents who wanted to keep track of time during meals and activities. The administration considered the clock a decoration and offered unsatisfactory alternatives, leaving the issue unresolved.
The facility failed to properly sanitize dishes and handle sanitized items, affecting all 66 residents. The dish machine was not dispensing sanitizer, and staff used a three-compartment sink but did not submerge dishes for the required 60 seconds. Additionally, the Cook did not follow proper sanitization procedures for food processor components.
The facility failed to label expiration dates on opened multi-dose vials and bottles of medication for five residents. During a review of the medication cart, it was found that insulin pens and eye drops were opened without expiration dates. The DON confirmed that medications should be dated when opened, as per the facility's policies.
The facility failed to provide the correct portion size of pureed hamburger to residents on pureed diets. A cook served meals using a three-compartment plate, placing pureed bread and hamburger in one section, resulting in only a half scoop of hamburger being served. The Dietary Manager confirmed that a full scoop should have been provided.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents with medical conditions requiring such measures. A resident with a urinary catheter and another with a tracheostomy lacked appropriate signage and PPE outside their rooms. Additionally, two residents with wounds and catheters did not have EBP signage or PPE available. The facility's policy and CDC guidelines were not followed, as evidenced by the absence of necessary precautions for these residents.
A resident received medications and insulin from a Wound Nurse who did not prepare them, contrary to facility policy. The LPN prepared the medications and insulin but did not administer them, leading to a breach in professional standards. The facility's policies require the nurse who prepares the medication to also administer it to ensure accuracy.
A facility failed to ensure proper assessment for a resident with dysphagia after a choking incident and did not follow safe transfer protocols for two residents. One resident was not referred back to speech therapy after choking, and another was transferred without a gait belt. Additionally, a resident fell during a transfer due to unlocked bed wheels.
A facility failed to maintain a resident's urinary catheter tubing and drainage bag below the bladder level, risking infection. The resident had a catheter due to urinary incontinence and neuromuscular dysfunction. A CNA was observed holding the catheter bag at waist level, causing urine backflow. The DON confirmed the need to keep the bag below the bladder to prevent UTIs, as per facility policy.
Two residents were not properly monitored during medication administration, leading to a deficiency. One resident with dementia had an unconsumed pill left on her bedside table, while another resident was found with a pain medication left on his bed, which he intended to take later. The facility lacked documentation for self-administration assessments, contrary to their policy.
A facility failed to act on a pharmacist's repeated requests for an end date on a resident's PRN Lorazepam order. Despite policy requiring a 14-day limit for PRN psychotropic medications, the order was renewed without criteria for extended use. The DON acknowledged that recommendations should be implemented within 48-72 hours, but this was not followed, resulting in a deficiency.
The facility failed to ensure PRN anti-psychotic medications had a stop date of fourteen days for two residents. One resident's lorazepam order for agitation lacked a stop date, and another's lorazepam order for anxiety was renewed without criteria for use beyond fourteen days, despite repeated requests from the consulting pharmacist. The facility's policy requires a time limit for PRN psychotropic medications, with physician evaluation after fourteen days.
A resident experienced significant delays in receiving their scheduled medications, resulting in a medication error rate of 17.86%. The LPN, unfamiliar with the residents, administered medications late, including insulin after the resident had eaten, contrary to the facility's policy. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not followed.
Two residents experienced significant medication administration errors in an LTC facility. One resident received their medications, including insulin, late due to an LPN being behind schedule, resulting in insulin being administered after breakfast. Another resident was given an excessive dose of Tramadol by a former nurse, who realized the mistake during a narcotics count. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not followed.
A resident with severe cognitive impairment and a history of wandering behaviors choked on floral foam from a recent activity due to inadequate supervision. Despite the care plan indicating the need for close monitoring, the resident accessed the foam and choked during dinner. Staff initiated the Heimlich maneuver, and the resident recovered after expelling the foam.
Failure to Perform and Document Required Vital Signs for Skilled Residents
Penalty
Summary
Surveyors identified that the facility did not follow its policy for obtaining vital signs and completing assessments for residents receiving skilled services. The facility’s Resident Examination and Assessment Policy dated 3/21/25 requires that residents receiving skilled services have an assessment completed at least once per shift, including vital signs (blood pressure, pulse, respirations, temperature) and, for respiratory assessments, oxygen saturation. The DON stated that residents at the facility for skilled therapy have a full assessment and vitals taken every 24 hours and as needed, and an LPN stated that residents on the skilled unit have vitals taken daily and as needed, with oxygen saturation checks being important for residents on oxygen. Despite these stated practices and policies, record review showed that required vital signs and assessments were not consistently obtained or documented for three residents on skilled services. For one resident admitted for therapy for a fractured sacrum and receiving 4 L oxygen via nasal cannula for shortness of breath and COPD, the vitals summary over a 13‑day stay showed oxygen saturation was checked only once, with pulse checked on 4 of 13 days, blood pressure on 5 of 13 days, respirations on 5 of 13 days, and temperature on 6 of 13 days. For a second resident admitted for skilled services, over 34 days blood pressure was checked on 19 days, oxygen saturation once, pulse on 15 days, respirations on 15 days, and temperature on 16 days; this resident reported that staff checked his blood pressure only every few days. For a third resident on skilled services for 16 days, blood pressure and pulse were each checked on 9 of 16 days, oxygen saturation once, respirations on 7 days, and temperature on 8 days; this resident reported that staff checked her pulse and blood pressure only occasionally. These observations, interviews, and record reviews demonstrate that the facility did not consistently perform and document the frequency of vital signs and assessments required by its policy for residents receiving skilled services.
Failure to Ensure Accurate Opioid Orders and Effective Pain Control
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for a resident admitted for subacute rehab following a fall that resulted in a pelvic fracture, multiple rib fractures, and fragile respiratory status. Hospital discharge instructions and an orthopedic after-visit summary specified hydrocodone-acetaminophen 10/325 mg every 4 hours as needed for moderate pain. However, upon admission, the physician called in an incorrect order for hydrocodone-acetaminophen 5/325 mg every 4 hours as needed, which staff later recognized was not adequately controlling the resident’s pain. A progress note on 3/26/26 documented that the resident’s pain was not well controlled with the 5/325 mg dose and that, after investigation, staff discovered the hospital discharge paperwork specified 10/325 mg every 4 hours as needed. The physician then gave approval to change the order to hydrocodone-acetaminophen 10/325 mg every 4 hours as needed for moderate pain. Despite this, the Medication Administration Record (MAR) shows the resident continued to receive the 5/325 mg dose from 3/25/26 to 3/30/26, and when the dose was changed on 3/31/26, it was entered as 10/325 mg every 6 hours as needed instead of every 4 hours. The April MAR continued to reflect the incorrect 10/325 mg every 6 hours as needed order until the family initiated discharge. Pain assessments documented that over multiple 5-day periods the resident’s pain frequently or almost constantly interfered with sleep and day-to-day activities, with pain intensities recorded as high as 9 out of 10, and the nurse practitioner noted the resident was having a lot of pain, difficulty moving, trouble sleeping, and poor mood due to pain. The DON stated that staff had faxed the physician to verify the order discrepancy but did not receive a response and failed to follow up, resulting in the MAR remaining incorrect and the resident’s pain not being managed in accordance with the prescribed every-4-hour regimen and the facility’s pain management policy.
Inadequate Controlled Substance Reconciliation and Missing Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate reconciliation and disposition of controlled substances and to maintain adequate policies governing these processes, resulting in the facility being unable to account for a resident’s controlled medications. Surveyors reviewed the North Unit Controlled Substance Accountability Record Card-Sheet Count (CCS) and found that the facility could not produce the CCS for a period covering several days when a resident’s hydrocodone-acetaminophen was delivered. The CCS is intended to track all controlled substance cards, bottles, patches, and the corresponding count sheets. However, multiple CCS entries contained mathematical and documentation errors that were carried forward across shifts before being identified or corrected, including instances where the number of sheets at the end of a shift did not match the additions and removals documented, and where counts changed without any recorded additions or subtractions. Specific CCS discrepancies included an entry where one sheet was removed and six added, but the total number of sheets remained unchanged, with this error carrying forward through several subsequent counts. Another entry showed one sheet removed and three added, but the total reflected an incorrect increase, followed by a shift where the total decreased without any documented changes. Additional entries showed inflated totals after adding new sheets, unexplained write-overs, and subsequent shifts with different starting counts that did not reconcile with prior entries. There were also instances where a sheet was documented as removed but the total number of sheets remained the same, and these errors continued across multiple days until the count changed without explanation. In one case, the number of controlled substance bottles decreased between shifts without any documented removal or wasting. The DON explained that the CCS is used as a deterrent to prevent staff from removing controlled substance count sheets and corresponding medication cards without detection, and acknowledged that the identified CCS errors did not add up. The DON stated she was not aware of the bottle discrepancy and confirmed that a CCS sheet was missing during the time frame when a resident’s hydrocodone-acetaminophen was delivered, and that a nurse reported her initials had been forged on the next available CCS sheet. The facility was unable to determine when the resident’s hydrocodone-acetaminophen went missing or who might have taken it. When the facility’s controlled substance policy was requested, only a section within the Medication Administration policy was provided, which addressed signing out controlled substances, counting at shift change, and documenting additions and removals. The policy did not address wasting of controlled substances, witnessing waste, storage requirements, handling of completed CCS or count sheets, responsibility for maintaining them, or reconciliation from one CCS sheet to the next.
Unaccounted Controlled Substance and Missing Narcotic Records for Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s controlled substance medication from misappropriation and to maintain accurate controlled substance accountability records. The resident was admitted with dementia, anxiety, and depression, and a recent MDS showed she was unable to respond to questions, could not complete a mental status interview, and had short- and long-term memory problems. Her MDS and MAR documentation for February showed she had no documented pain and had not received PRN pain medication in the prior five days, with pain assessments consistently recorded as 0/10. Despite this, the resident had an active PRN order for hydrocodone-acetaminophen 5-325 mg every 12 hours as needed for pain, with only one documented administration in mid-February and no further documented administrations in February or early March prior to the order being changed to scheduled dosing. Pharmacy records showed that 60 tablets of hydrocodone-acetaminophen were delivered for the resident on 2/18/26, which at a twice-daily maximum frequency should have lasted approximately 30 days. However, the facility could not produce the controlled substance count sheets for this medication for February or the corresponding Controlled Substance Accountability Record Card-Sheet Count (CCS) for the period immediately following the delivery. The only hydrocodone-acetaminophen count sheets available for the resident began on 3/6/26, and the CCS records had a gap between the morning of 2/18/26 and the evening of 2/20/26. The DON acknowledged that the facility was unable to locate the February hydrocodone-acetaminophen count sheets or the CCS for the time period in question and that there was no record the medications were destroyed, stating that the facility could not account for the resident’s hydrocodone-acetaminophen. Staff interviews further highlighted irregularities in the documentation and handling of the controlled substance. An LPN reported she was the nurse who received the hydrocodone-acetaminophen on 2/18/26, completed the controlled substance count sheets, documented receipt of two new cards on the CCS, and placed the cards in the locked medication cart. She later disputed initials attributed to her on the 2/20/26 CCS entry, stating they were not hers and that she had left work earlier than the time documented, and expressed anger that someone had forged her initials. The DON confirmed that this LPN disputed the initials on the CCS. Multiple nursing staff, including LPNs and CNAs, stated they rarely or never observed the resident in pain and could not recall administering or needing to administer PRN hydrocodone-acetaminophen, despite the pharmacy delivery and lack of corresponding count sheets. The Administrator acknowledged missing count sheets, a missing CCS for the relevant period, minimal documented pain, the early refill denial, and the potential forgery of initials, while the facility’s abuse prevention policy defined misappropriation as wrongful use of a resident’s belongings or money without consent.
Failure to Report Alleged Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident’s narcotic medication to the State Agency and local law enforcement as required by its Abuse Prevention Program. On 3/4/26, the Administrator (V1) was informed of a potential misappropriation involving a resident’s hydrocodone-acetaminophen after a discrepancy was identified between narcotic count records and documented administration. The facility’s investigation report attributed the discrepancy to possible documentation errors, including failure to sign out PRN narcotic medications at the time of administration, incomplete or missing entries on narcotic log sheets, and improper paper handling, and concluded the concern of narcotic misappropriation was unsubstantiated. Despite this initial concern and the facility’s own policy defining misappropriation of resident property and requiring immediate reporting of such allegations to the Department of Public Health and local law enforcement when there is reasonable suspicion a crime has been committed, the allegation was not reported. Record review showed that the resident’s February 2026 MAR included an order to screen for pain every shift, with staff documenting a pain score of 0 on a 0–10 scale for the entire month. The MAR also showed an order for hydrocodone-acetaminophen 5-325 mg to be given every 12 hours PRN for pain, with only one documented administration on 2/14/26 at 2:34 PM from an order that began on 11/11/25 and was discontinued on 3/4/26. Pharmacy records showed 60 tablets of hydrocodone-acetaminophen were delivered for this resident on 2/18/26, which, at a maximum frequency of twice daily, should have lasted approximately 30 days. The DON (V2) stated the facility was unable to locate the resident’s controlled substance count sheets for this medication and that the 60 tablets delivered on 2/18/26 could not be accounted for. On 4/2/26, the Administrator acknowledged that, in hindsight, this allegation should have been reported to the State Agency and confirmed it had not been reported to local law enforcement, contrary to the facility’s Abuse Prevention Program policy.
Failure to Prevent Wandering Resident From Entering Another Resident’s Room and Bed
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent a known confused, wandering resident from entering another resident’s room and bed. The female resident had Alzheimer’s disease, dementia, severe cognitive impairment per BIMS, a history of wandering, and was assessed as high risk for abuse/neglect and for wandering/elopement. Her care plan identified her as an elopement risk/wanderer related to impaired safety awareness, dementia, and Alzheimer’s disease, and included interventions such as providing pleasant diversions, structured activities, walking inside, toileting, and reorientation strategies. Despite these identified risks and planned interventions, she was able to leave the common area unsupervised and enter a male resident’s room. On the evening of the incident, staff documentation and interviews show that the female resident was last seen in the 200-unit common area near the nurse’s station after dinner, seated on a couch around 6:30 p.m., with an activity aide assigned to remain in the common area and keep residents engaged. The activity aide reported that she did not engage the resident in 1:1 activities and later heard commotion down the hall around 7:00–7:30 p.m., at which time she noticed the resident was no longer in the common area. The aide did not know when the resident had left or whether she herself had left the common area. Another CNA stated that the female resident wanders often, goes into other residents’ beds as a typical behavior, and is usually redirected when seen, but on this occasion staff were likely busy and no one saw her walking down the hall. During this period of inadequate supervision and failure to effectively implement the resident’s care-planned interventions, the female resident entered a male resident’s room. The final incident report documented that staff entered the room and observed the fully dressed female resident lying in bed with the male resident, who was unclothed. Both residents’ hands were at their sides or resting on the bed, no movement or sexual activity was observed, and both appeared calm with no signs of distress. Post-incident assessments found no injuries or signs of trauma, and both residents were unable to recall how or why they were in bed together. The male resident later reported that the woman had wandered into his room, sat on his bed, and would not leave despite his requests, and he stated that he did not lie in bed with her or do anything with her. The facility’s failure to prevent the high-risk, cognitively impaired resident from wandering into another resident’s room resulted in both residents being found in bed together and the male resident being inappropriately exposed.
Failure to Send Dermatology Referrals for Residents With Ongoing Rashes
Penalty
Summary
The facility failed to ensure dermatologist referrals were sent for residents with ongoing rashes as ordered by the physician for six of ten residents reviewed for quality of care, including R1, R7, R8, R9, and R10. R1’s record showed a dermatologist referral order was entered due to an ongoing rash not improving with treatment, and the facility’s rash data showed a torso rash beginning on October 11, 2025. On November 25, 2025, R1 stated he had a rash on both arms and other areas of his body, that cream was applied but made the itching worse, and that the facility did not know where the rash came from. R7’s record showed a dermatologist referral order for an ongoing rash, and the rash data showed a rash to the arms and back off and on for three months. R8’s record showed a dermatologist referral order for an ongoing rash, and the rash data showed a rash to the arms and chest since July 2025. R9’s record showed a dermatologist referral order for an ongoing rash, and the rash data showed a rash to the right shoulder beginning on October 16, 2025. R10’s record showed a dermatologist referral order for an ongoing rash. The wound care nurse stated there were multiple residents experiencing rashes, some had received dermatologist referrals, some rashes did not improve after physician-ordered treatments, and some residents were still itchy. The medical records/human resources staff member stated she had recently taken over scheduling appointments, that the doctor entered the referral order in the computer system and the nurse gave her the order, and that she did not have fax confirmations for R1 and R7 through R10. She also stated she was still waiting on a call back for R9 and R10, and that she called the dermatologist office on November 25, 2025 to make R1 and R7’s appointments because they had not been scheduled prior to that day.
Failure to Provide Appropriately Prepared Food for Resident with Chewing Difficulties
Penalty
Summary
The facility failed to ensure that food was prepared in a form appropriate to meet the needs of a resident with chewing difficulties, resulting in a choking incident. The resident had a documented history of vascular parkinsonism, dementia, anxiety, depression, dysphagia, and cognitive communication deficit. Orders and care plans indicated the resident required a mechanical soft diet, with specific recommendations for ground ham according to the facility's dietary spreadsheet. However, the resident was served diced ham instead of ground ham during a meal, which did not align with the individualized dietary needs outlined for mechanical soft diets. During the meal, the resident began to choke on the diced ham, exhibiting signs of distress such as gurgling sounds, blue lips, and inability to cough up the food. A CNA responded by performing the Heimlich maneuver, after which the resident expelled the food and was able to breathe and speak again. Staff interviews revealed uncertainty and inconsistency regarding the appropriate texture for mechanical soft diets, with some staff believing diced ham was acceptable based on past guidance, despite the dietary spreadsheet specifying ground ham for this diet type. Further review of facility policies and interviews with dietary and clinical staff highlighted a lack of clarity and adherence to individualized dietary modifications. The facility's own policy required that mechanically altered diets be individualized and that staff follow the dietary spreadsheets, which in this case specified ground ham. Despite this, diced ham was served, and staff were not uniformly aware of the specific requirements for the resident's diet, directly leading to the choking incident.
Resident Refrigerator Temperature Out of Compliance
Penalty
Summary
The facility failed to ensure the resident food and drink refrigerator was maintained at or below 41 degrees Fahrenheit. Surveyors observed the refrigerator at 44 degrees Fahrenheit on 9/10/25 at 12:54 PM, and it contained many items of food and drink. The facility’s temperature log for September 2025 showed the refrigerator ranged from 44 to 48 degrees Fahrenheit from 9/1/25 through 9/10/25. During interview, the DON stated that night shift nurses were responsible for checking the refrigerator temperature and that it should be below 42 degrees Fahrenheit, but if it was not, they should adjust the dial and recheck it. The DON also reviewed the form on the front of the refrigerator and noted it did not provide directions for nurses on the acceptable temperature or what actions to take if the temperature was not in a safe zone. The facility policy stated that all resident refrigerators must maintain safe internal temperatures and that if the temperature is not maintained at 41 degrees Fahrenheit or below, the food will be discarded.
Unsafe Hot Liquid Service and Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature for all residents. The facility roster showed 70 residents. On 9/9/25, the Dietary Manager showed surveyors the coffee and hot water machine and stated it was set to 205 degrees Fahrenheit by the servicing company. That day, hot coffee was served to four residents, and each resident stated the coffee was too hot to drink and needed to cool before drinking; the coffee was observed steaming in all four mugs. The next morning, the Dietary Manager measured hot coffee at 173 degrees Fahrenheit and hot water at 154 degrees Fahrenheit as they were poured into carafes for the dining area, and later measured hot coffee at 170 degrees Fahrenheit and hot water at 138 degrees Fahrenheit being served to the first resident. The DON stated she was not sure whether hot liquid assessments were done or what the safe temperature should be, and the Regional Director of Operations stated the facility had never done hot liquid assessments and that the policy for serving hot liquids said 180 degrees or below were safe to serve to residents. The facility also failed to ensure a resident was transferred with a gait belt. R41 had diagnoses including history of falls, type 2 diabetes, chronic kidney disease, depression, and muscle weakness, and the facility assessment showed no cognitive impairment and substantial/maximal assist needed for ambulation. Physician orders directed 1 assist and gait belt for all transfers, the fall risk assessment identified R41 as high fall risk, and the care plan stated R41 ambulated with restorative aide assistance, a gait belt, and a four-wheeled walker. Nursing progress notes documented a fall on 8/15/25 during ambulation when the resident was assisted to the toilet without a gait belt, and the resident later reported she fell while going to the bathroom at night because the aide did not have the belt on her. A CNA stated she transferred R41 to the bathroom without a gait belt and the resident started to fall sideways and fell onto her bottom and side. The DON stated staff should have used a gait belt when transferring R41, and the facility policy stated gait belts shall be used unless the resident is independent with ambulation, supervision only, or contraindicated in the care plan.
Infection Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not prevent cross contamination during incontinence care for a resident with diagnoses including right sided hemiplegia, Parkinson’s disease, chronic respiratory failure with hypoxia, cerebral infarction, type 2 diabetes mellitus, paranoid schizophrenia, and other conditions. During care, three CNAs entered the resident’s room and applied gloves. One CNA provided perineal care, handled the resident’s urinal, and continued touching clean items such as the blanket, sheet, washcloth, towel, incontinence brief, and pad without changing gloves at the points described. Another CNA also provided care and did not change gloves before securing the incontinence brief. Staff interviews confirmed gloves should be changed when moving from dirty to clean, and the DON stated gloves are to be changed when going from dirty to clean for infection control. The resident’s care plan identified him as incontinent of bowel and bladder and dependent on staff for peri care and linen changes. The facility also failed to thoroughly disinfect resident equipment after use. An LPN obtained a blood glucose reading for a resident with type 2 diabetes mellitus and placed the glucometer in the top drawer of the med cart before disinfecting it. When questioned, the LPN stated she forgot and then wiped the glucometer with a germicidal disposable wipe after it had already been returned to the cart. The resident had orders for blood glucose checks as needed and insulin lispro per sliding scale before meals and at bedtime. In addition, the facility failed to ensure hand hygiene was completed after glove removal during medication administration and failed to disinfect a blood pressure wrist cuff after use. The same LPN applied gloves, instilled eye drops into a resident with dementia and hypertension, removed the gloves, and returned to the med cart without observed hand hygiene. The LPN later stated she should have performed hand hygiene after removing her gloves. The LPN also used a blood pressure wrist cuff on another resident with hypotension, returned it to the med cart without observed sanitizing, and then administered the resident’s blood pressure medication. The DON/Infection Preventionist stated hand hygiene should be performed after administering eye drops, removing gloves, and between residents, and that resident equipment should be wiped down with a cavi wipe and held for the required contact time. Facility policies for medication administration, hand hygiene, and eye medication administration all required hand hygiene after glove removal and infection control procedures during medication administration.
Failure to Report Allegations of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the local health department and failed to report two allegations of misappropriation of resident property to local authorities. The deficiency involved 2 of 3 residents, including R54 and R61, in a sample of 36. The facility’s Abuse Prevention Program stated that any allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property must be reported immediately to the Department of Public Health, and that local law enforcement must also be contacted when there is reasonable suspicion that a crime has been committed in the facility by a person other than a resident. R61’s record showed an admission date of 4/7/25. An investigation dated 8/27/25 documented that R61’s sister-in-law reported $180 missing after giving R61 the money in $20 bills. R61 stated she placed the money in her purse, which she kept around her neck and removed only when sleeping. The investigation included review of camera footage and staff interviews, and the writer documented that staff entered rooms briefly for rounds and were in pairs for care and longer visits. R61 and her sister-in-law were told what the camera review showed, and both stated they wanted to move on and did not want to proceed further. The investigation also noted that the money had not been found. On 9/9/25 and 9/10/25, R61 stated she believed someone had taken the money and said she had checked her wallet/purse before it went missing. Her sister-in-law stated she believed the money had been in R61’s billfold or black purse and said she never spoke to police about the incident. Staff members described R61 as alert and oriented, without behaviors, and said she carried her black purse with her everywhere. The Administrator stated the missing money was not reported to the local health department or local authorities because the family and R61 did not want anything done and thought the money might be found, and she acknowledged the money still had not been found more than two weeks later. The Administrator also stated she would call police only if there was immediate danger and said she had never heard that reasonable suspicion of a crime had to be reported to police.
Hospice Mattress Not Implemented as Ordered
Penalty
Summary
The facility failed to ensure hospice interventions were implemented as ordered for one resident who was admitted to hospice on 8/18/25 and had diagnoses including dementia, muscle weakness, dysphagia, abnormal posture, osteoarthritis, restlessness, agitation, severe vascular dementia with mood disturbance, unspecified psychosis, hyperlipidemia, hypertension, hypothyroidism, and aortic valve stenosis. On 9/9/25, the resident was observed lying on her left side in bed asleep with an air mattress in place that was not turned on, even though the setting on the mattress was at 6. A CNA confirmed the mattress was not on and said it should be turned on, while an LPN later stated the mattress had been provided by hospice because the resident was frail and small and bony, and was intended to prevent pressure injury. An LPN then turned on the mattress and confirmed it worked, but it had not been turned on before that time. The physician order for the air mattress setting was not obtained until 9/9/25 and stated the mattress should be set at 3. The hospice note dated 9/3/25 did not include information about the air mattress or a related plan of care. The facility care plan dated 9/7/25 did not show the resident was receiving hospice care, and when revised on 9/10/25 to include a low air loss mattress under the pressure ulcer/skin breakdown focus, it still did not include the mattress setting. The DON stated the facility had called hospice for the mattress settings, and an LPN stated she did not know anything about the hospice care plan for the resident.
Pressure ulcer monitoring and care planning failures
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient because the facility failed to complete weekly wound assessments for a resident with existing skin breakdown and failed to identify a new pressure ulcer when it was observed. R5 had diagnoses including vascular parkinsonism, dementia without behaviors, anxiety disorder, depression, mood disorder, and anemia, and the facility assessment identified mild cognitive impairment and one stage 2 pressure ulcer. R5’s care plan addressed pressure ulcers/skin breakdown related to advanced age, impaired cognition, impaired perfusion, chronic kidney disease, assistance with ADLs, incontinence, and friction/shear, with a low pressure air mattress listed. However, no weekly wound assessments were present in the electronic record from 8/6/25 through 9/11/25, and the wound nurse stated R5 had not been seen or had a wound assessment since 8/5/25 by the wound NP. During the survey, the wound nurse completed an assessment and the surveyor identified a new open pressure ulcer on R5. The wound nurse measured the wound and stated she had not been notified of any new skin concerns before the assessment. The regional director of operations stated weekly wound assessments had not been getting done for R5 and also stated that if a wound is open it is a stage 2, not a stage 1. The facility policy required weekly measurements by the same licensed person when possible and required that a skin issue be measured when discovered. For R39, the facility failed to develop a specific pressure ulcer care plan for a new deep tissue injury to the right heel. Although the wound care notes identified the heel injury and directed heel offloading with a heel protector or pillow, the care plan only addressed general pressure ulcer prevention and did not include a specific heel offloading intervention or a specific pressure injury care plan. Staff stated CNA charting pulls interventions from the care plan, and the wound nurse stated residents with pressure injuries should have a specific care plan showing the injury and interventions to address it; she stated R39 did not have that type of care plan and should have both.
Inaccurate Weights and Unimplemented RD Recommendation
Penalty
Summary
The facility failed to obtain accurate weights for a resident with diagnoses including cerebral infarction, peripheral vascular disease, flaccid hemiplegia, and absence of the left leg above the knee. The resident’s care plan identified him as at risk for nutritional problems and stated that the RD would evaluate and make diet change recommendations as needed. The resident told surveyors he thought he had lost weight but was not sure how much and said he was weighed monthly. The weight log showed a 23.2 lb gain within 3 days and then a 21.5 lb loss within 15 days, but there was no documentation that the resident was re-weighed after either abnormal weight entry. The RD note documented significant weight loss in the last 30 days and recommended weekly weights for 4 weeks to monitor the resident. However, the resident had no physician order for weekly weights in the September 2025 orders, and staff stated the resident was not on the weekly weight list. The LPN, lead CNA, wound care nurse, and DON each described that RD recommendations were expected to be sent to the physician for orders and entered into the chart, but this was not done for the weekly weights recommendation. The facility policy required any weight change of 5% or more to be retaken for confirmation and, if verified, for nursing to notify the Dietician in writing.
Inappropriate Language Used by Beautician During Resident Care
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident was treated with dignity and respect during a personal care service. A beautician, while providing hair care to a resident with severe cognitive impairment, used inappropriate language by asking the resident if she likes to 'b***h a lot.' This incident was overheard by someone outside the beauty salon, leading to the beautician being removed from the facility and an investigation being initiated. The beautician admitted to using the inappropriate term and stated it was meant to engage the resident, not to harass or threaten her. The resident involved, who has a history of dementia and other medical conditions, did not recall the incident due to her impaired cognition. The facility's administrator was informed of the incident and took steps to address it, including notifying the resident's family and the medical doctor. The beautician had previously attended an abuse in-service training, and the facility's policy emphasizes the importance of treating residents with respect and dignity. Despite the beautician's familiarity with the resident and her admission of poor word choice, the facility's policy and expectations for professional conduct were not upheld in this instance.
Failure to Administer IV Flushes Due to RN Unavailability
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, identified as R1, who required peripheral intravenous access site flushing. R1 was admitted with multiple diagnoses, including hypertension, systemic sclerosis, chronic heart failure, hepatic failure, atrial fibrillation, and reduced mobility. The electronic Medication Administration Record (eMAR) for February 2025 indicated an order for Sodium Chloride Solution 0.9% to be used as a flush every 8 hours. However, the eMAR showed that the IV flushes were not completed on several occasions due to the unavailability of a Registered Nurse (RN) to administer them, specifically on the overnight shifts of 2/2/25, 2/3/25, 2/6/25, and 2/7/25. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed that the facility's policy does not allow LPNs to perform IV flushes, and RNs were responsible for this task. The DON acknowledged that some of R1's flushes were missed, primarily due to an RN calling off during the night shift, and there was no on-call notification system in place to address the absence. Additionally, the facility lacked a specific policy for the maintenance and flushing of peripheral IVs, relying instead on a general policy for catheter insertion and care, which did not cover the necessary procedures for IV flushes.
Facility Fails to Provide Homelike Environment Due to Lack of Dining Room Clock
Penalty
Summary
The facility failed to provide a homelike environment for four residents, as evidenced by the lack of a clock in the dining room, which was a repeated concern raised by the residents. The residents, who were cognitively intact, expressed their dissatisfaction with the absence of a clock, which they deemed necessary for keeping track of time during meals, activities, and appointments. Despite the residents' willingness to purchase a clock themselves, the facility administration, including the Regional Director of Clinical Operations, deemed a clock as a decoration and decided against replacing it. The residents, including the resident council president, consistently brought up the issue of the missing clock in resident council meetings. The previous clock had fallen and broken, and despite ongoing requests for a replacement, the facility did not address the residents' concerns. The residents expressed that knowing the time was important for their daily activities and overall satisfaction, yet their requests were dismissed by the facility's administration. The facility's administration, including the Administrator and the Regional Director of Clinical Operations, acknowledged the residents' requests but maintained that the issue was resolved by suggesting alternative ways for residents to know the time, such as asking staff or checking in their rooms. However, these alternatives did not satisfy the residents' needs, and the lack of a clock in the dining room remained unresolved, contributing to the deficiency in providing a homelike environment.
Improper Dish Sanitization and Handling
Penalty
Summary
The facility failed to ensure proper sanitization of dishes and handling of sanitized items, which could potentially affect all 66 residents. During an observation, the Dietary Manager discovered that the dish machine was not dispensing sanitizer, and maintenance was called to fix it. In the meantime, staff were instructed to use a three-compartment sink for dishwashing. However, the Dietary Aide did not submerge dishes in the sanitizing solution for the required 60 seconds and handled sanitized dishes with unclean hands after touching the trash. Additionally, the Cook did not follow proper sanitization procedures while preparing pureed food for lunch. The Cook failed to submerge the food processor components in the sanitizing solution for the required time, removing them prematurely. The facility's policy and the sanitizer product label both specify a minimum contact time of 60 seconds for effective sanitization, which was not adhered to in these instances.
Failure to Label Expiration Dates on Opened Medications
Penalty
Summary
The facility failed to ensure that opened, multi-dose vials and bottles of medication, including insulin pens and eye drops, were labeled with expiration dates for five residents. During an inspection of the 100-wing medication cart, it was observed that medications for five residents were opened but lacked identified expiration dates. These medications included Glargine insulin for one resident, Fiasp insulin for another, Tresiba and Lispro insulin for a third, Lantus insulin for a fourth, and Latanoprost eye drops for a fifth resident. The Director of Nursing confirmed that insulin pens and bottles of eye drops should be dated when opened to inform staff of their expiration. The facility's Medication Administration policy, dated July 28, 2023, requires that the expiration or beyond-use date on the medication label be checked before administration, and that the date of opening a multi-dose container be recorded on the container. Similarly, the Insulin Administration policy mandates checking the expiration date when drawing from an opened multi-dose vial and recording the expiration date when opening a new vial. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Deficiency in Pureed Diet Portion Sizes
Penalty
Summary
The facility failed to ensure that residents receiving a pureed diet were provided with the correct portion size of pureed hamburger. This deficiency was observed in four residents who were on pureed diets and used three-compartment plates for their meals. On the specified date, the cook, identified as V15, served lunch and placed pureed bread and pureed hamburger in one compartment, pureed green beans in the second, and mashed potatoes in the third. Although the correct scoop sizes were available, V15 accommodated the three-compartment plate by placing one full scoop of pureed bread and only approximately a half scoop of pureed hamburger in the same section. The Dietary Manager, V14, later confirmed that each resident should have received a full scoop of pureed hamburger.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for four residents who required such measures due to their medical conditions. Resident 51, who had a urinary catheter, did not have appropriate signage or personal protective equipment (PPE) available outside his room. A Certified Nursing Assistant (CNA) was observed providing care without wearing a protective gown, despite the resident's care plan indicating the need for EBP. Similarly, Resident 10, who had a tracheostomy, lacked signage and PPE outside her room, and she was not included on the facility's list of residents requiring EBP. Resident 13, with a history of methicillin-resistant Staphylococcus aureus infection and open wounds, also did not have EBP signage or PPE available. Resident 14, who had a urinary catheter, was similarly lacking in EBP signage and PPE. The facility's policy and CDC guidelines require EBP for residents with wounds or urinary catheters, but these were not adequately implemented, as evidenced by the absence of necessary signage and PPE for the affected residents.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure professional standards were met during medication administration for a resident, identified as R23. The resident's Medication Administration Record (MAR) included orders for multiple medications, including Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin. On the morning of July 29, 2024, an LPN dispensed R23's morning medications into a cup without reviewing them with another nurse, a Wound Nurse, who was present. The Wound Nurse then administered the medications to R23 without verifying the medications or dosages. Additionally, the Wound Nurse checked R23's blood glucose level, which was 260 mg/dl, and reported it to the LPN. The LPN prepared the insulin pens for Fiasp and Lantus but did not double-check the dosages with the Wound Nurse before handing them over for administration. The facility's policies on insulin and medication administration clearly state that the nurse who draws up the medication must be the one to administer it to ensure accuracy. However, in this instance, the Wound Nurse administered the medications and insulin prepared by the LPN, contrary to the facility's policies. The Director of Nursing confirmed that the nurse who prepares the medication should also administer it to ensure the correct dosage and resident. This deviation from established procedures led to the deficiency in medication administration for R23.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure adequate assessment and intervention for a resident with dysphagia following a choking episode. Resident R10, who has a history of Parkinsonism, tracheostomy status, gastro-esophageal reflux disease, dysphagia, seizures, and traumatic brain injury, experienced a choking incident during a meal. Despite coughing and requiring assistance to clear her airway, R10 was not referred back to speech therapy for evaluation after the incident. The Speech Language Pathologist was unaware of the choking episode and stated that an evaluation should have been conducted. The Director of Nursing confirmed that R10 was sent to the hospital for evaluation but did not have any diet changes or a referral to speech therapy afterward. The facility also failed to ensure safe transfer practices for residents. Resident R51, who has limited physical mobility and is at risk for falls, was assisted to stand by a CNA without the use of a gait belt, contrary to the facility's policy. Additionally, Resident R40 experienced a fall during a transfer when a CNA did not check that the bed wheels were locked, causing the bed to roll away. These incidents highlight lapses in following established safety protocols for resident transfers, contributing to unsafe conditions for the residents involved.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain a resident's urinary catheter tubing and drainage bag below the level of the bladder, which is necessary to prevent infection. The resident, identified as R51, had a urinary catheter due to urinary incontinence and neuromuscular dysfunction of the bladder. The care plan specified that the catheter bag and tubing should be positioned below the bladder. However, during an observation, a Certified Nursing Assistant (CNA) was seen holding the urinary catheter bag at her waist, which was at the level of the resident's head, while the resident attempted to reposition himself in a recliner. This improper positioning led to an observable backflow of urine in the catheter tubing towards the resident. The Director of Nursing confirmed that the catheter bag and tubing should be kept below the bladder to prevent backflow and potential urinary tract infections. The facility's policy also stated that the drainage bag must be positioned lower than the bladder at all times to prevent backflow.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring of medication administration for two residents, leading to a deficiency in pharmaceutical services. On one occasion, a resident with dementia was found with an orange pill left in a medicine cup on her bedside table, which she expressed a desire to discard. This indicates that the nurse did not observe the resident taking her medication, nor did they document her refusal to take it. The resident's admission record confirmed her diagnosis of dementia, which necessitates careful monitoring during medication administration. Another resident was found with a pill in a medicine cup on his bed, which he intended to take later for pain management. The resident reported that the nurse left the medication while he was still asleep, and he preferred to take it in the afternoon when his pain typically began. Despite the resident's routine of taking the medication at a different time, there was no documentation of a physician's order to accommodate this schedule. The facility's policy requires an assessment and documentation for residents self-administering medications, but no such documentation was available for these residents.
Failure to Address Pharmacist's Recommendations for PRN Medication
Penalty
Summary
The facility failed to respond to a consulting pharmacist's repeated notifications regarding a resident's PRN anti-anxiety medication order that lacked an end date. The resident, identified as R6, had a physician order for Lorazepam 0.5 mg every 4 hours as needed for anxiety, dated 4/5/24, without a specified stop date. The consulting pharmacist, V17, conducted medication regimen reviews on 4/25/24, 5/16/24, and 6/21/24, each time requesting a stop date for the PRN Lorazepam order. Despite these requests, the facility did not act upon the pharmacist's recommendations. The facility's policy on psychotropic medications requires that new PRN orders for such medications have a time limit of fourteen days, after which the prescribing physician must evaluate the need for continued use. On 6/23/24, a note to the attending physician indicated a third request for criteria beyond 14 days for the PRN Lorazepam order. The physician renewed the order due to the resident's agitation and psychosis. The Director of Nursing, V2, stated that pharmacist recommendations should be implemented within 48-72 hours, but this was not done in this case, leading to the deficiency.
Failure to Implement Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed (PRN) anti-psychotic medications had a stop date of fourteen days, as required by their policy. This deficiency was identified in two residents. The first resident had an order for lorazepam oral concentrate, prescribed for agitation related to unspecified psychosis, which started on December 29, 2023, and lacked a stop date. This oversight indicates a failure to adhere to the facility's policy that mandates a time limit for PRN psychotropic medications. The second resident had a new physician order for lorazepam, prescribed for anxiety, which also did not include a stop date. Despite repeated requests from the consulting pharmacist for a stop date, the order was renewed without the necessary criteria for use beyond fourteen days. The facility's policy clearly states that new PRN orders for psychotropic medications should have a time limit of fourteen days, after which the prescribing physician must evaluate the need for continued use. The consulting pharmacist confirmed the requirement for an end date and the need for physician evaluation after fourteen days.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to administer medications on time and as ordered, resulting in a medication error rate of 17.86%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the case of one resident, who was supposed to receive multiple medications at specific times. The resident's Medication Administration Record (MAR) indicated orders for Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin, all of which were scheduled for administration at specific times throughout the day. However, on the morning of July 29, 2024, the resident reported not having received any of their morning medications by 9:18 AM, despite them being scheduled for earlier administration. The delay in medication administration was attributed to the LPN being unfamiliar with the residents on the wing, causing them to fall behind schedule. The resident's blood glucose level was checked after they had already eaten breakfast, contrary to the facility's policy of checking it 30 minutes prior to a meal. The LPN and Wound Nurse administered the resident's medications and insulin late, with the insulin being given after the resident had already eaten. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed, leading to significant medication errors for two residents. For one resident, the July 2024 Medication Administration Record (MAR) indicated that medications, including Depakote, Lantus insulin, Fiasp insulin, Norco, and Pregabalin, were not administered at the scheduled times. On a specific day, the resident reported not receiving their morning medications on time, and the LPN admitted to being behind schedule. The resident's blood glucose level was checked after breakfast, contrary to the protocol of checking it thirty minutes prior to a meal. Consequently, the resident received their insulin doses late, after having already eaten breakfast. Another resident experienced a medication error when a former nurse administered an excessive dose of Tramadol, totaling 200 mg instead of the prescribed 50 mg every six hours as needed. The error was discovered at the end of the nurse's shift during a narcotics count. The resident's physician was notified, and the resident was monitored for adverse effects, with no serious side effects noted. The facility's Medication Administration policy mandates that medications be administered safely, timely, and within one hour of the prescribed time, which was not adhered to in these instances.
Inadequate Supervision Leads to Resident Choking on Non-Food Item
Penalty
Summary
The facility failed to supervise a resident with dementia adequately, leading to a choking incident on a non-food item. The resident, who had severe cognitive impairment and a history of wandering behaviors, was known to place non-food items in her mouth. Despite this, the resident was able to access floral foam from a Mother's Day activity, which she subsequently choked on. The incident occurred during dinner when the resident walked into the dining room showing signs of choking. Staff initiated the Heimlich maneuver, and the resident eventually expelled the foam and recovered. The resident's care plan indicated that she required supervision to prevent her from placing non-food items in her mouth. However, on the day of the incident, the staff on duty did not adequately monitor her movements, allowing her to access and ingest the foam. Multiple CNAs and an LPN were present during the incident, and they confirmed that the resident had a habit of wandering into other residents' rooms and taking items. The floral foam was part of a recent activity, and pieces of it were found scattered in various rooms, indicating a lack of thorough cleanup and supervision. The facility's policy on safety and supervision emphasized the importance of making the environment as free from accident hazards as possible and tailoring supervision to individual residents' needs. Despite this policy, the resident was able to access a hazardous item, leading to the choking incident. The staff's failure to monitor the resident adequately and ensure the environment was free from such hazards directly contributed to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 116 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Pinecrest | 5.4 mi | ★★★★★ | 10 | 0 |
| Neighbors Health Center | 9.1 mi | ★★★★★ | 2 | 0 |
| Manor Court Of Rochelle | 9.9 mi | ★★★★★ | 3 | 0 |
| Franklin Grove Living And Rehab | 11.2 mi | ★★★★★ | 15 | 0 |
| Polo Rehabilitation & Hcc | 11.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oregon Living And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.