Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Polo Rehabilitation & Hcc during CMS and state inspections, most recent first.
A resident with depression did not receive the correct dosage of Doxepin as ordered by the physician. The order to reduce the dosage from 10 mg to 5 mg was not implemented because the facility continued to administer 10 mg capsules, and the necessary adjustments to provide the correct dosage in an elixir form were not made. Staff interviews revealed that the discrepancy was not addressed, and the facility's Medication Pass Policy was not followed.
The facility failed to provide a smooth consistency pureed diet for five residents. A dietary staff member prepared pureed salisbury steak and vegetables, but a test tray revealed that both contained chunks, requiring chewing. The Dietary Manager confirmed the inconsistency, noting that pureed food should have a baby food consistency, as per the facility's guidelines.
A resident in a LTC facility was subjected to verbal abuse by her roommate, who accused her of theft and used profane language. A CNA witnessed the incident and reported it to the administrator, who then had the aggressive resident moved to another room. The facility's policy prohibits such abuse, but it failed to prevent this occurrence.
A facility failed to follow its abuse policy when a resident accused her roommate of stealing a phone and used profane language towards her. The incident was reported to the administrator, who did not consider it abuse and did not investigate or report it, attributing the behavior to dementia-like symptoms. This inaction violated the facility's policy, which requires identification, investigation, and reporting of abuse.
A resident was found with untreated wounds on the right arm and leg, with no treatment orders obtained by the facility. The resident reported that the dressings had not been checked or changed for several days. The DON confirmed the absence of treatment orders and acknowledged the lack of wound treatment policies, leading to inadequate care for the resident's wounds.
A resident's pressure ulcer dressings were not changed as ordered, with dressings dated two days prior still in place. The resident reported that a nurse intended to change them but did not return. The physician's orders required daily changes, confirmed by the DON. The resident had stage 2 and stage 3 pressure ulcers.
A resident received 39 doses of expired Morphine Sulfate over a two-month period. The medication had an expiration date of May 25, but doses were administered from May 30 through late July. A nurse confirmed the medication's expiration, and the DON stated that expired medications should not be used. The facility's policy requires discarding medications after their expiration date.
A facility failed to ensure a resident's PRN psychotropic medication had a stop date, as required by regulations. The resident had an order for clonazepam 0.25 mg every 8 hours as needed, without a stop date, exceeding the 14-day limit for PRN orders. The Director of Nursing was unsure if a response to pharmacy recommendations had been received. Facility policy requires PRN psychotropic medications to be limited to 14 days unless extended by a physician.
A facility failed to secure controlled medications with a two-lock system. The medication room door was found open, and the refrigerator containing narcotics, including a resident's Morphine Sulfate, was unlocked. The resident had a physician's order for Morphine Sulfate for pain or shortness of breath. The DON and a RN confirmed that both the medication room and refrigerator should have been locked.
Failure to Administer Correct Medication Dosage
Penalty
Summary
The facility failed to ensure that a resident received the correct physician-ordered dosage of medication following an order change. The resident, a male with a diagnosis of depression, was supposed to have his Doxepin dosage reduced from 10 mg to 5 mg as per a physician's order on March 14, 2024. However, the facility continued to administer 10 mg capsules because Doxepin does not come in a 5 mg capsule form, and the necessary adjustments to provide the correct dosage in an elixir form were not made. The facility's progress notes indicated that the VA pharmacy required a revised prescription to provide the medication in the correct form, but this was not followed through. Observations and interviews with facility staff revealed that the medication administration did not align with the physician's order, and the discrepancy was not addressed appropriately. Both the Registered Nurse and Licensed Practical Nurse acknowledged that the medication provided did not match the order and that the physician and pharmacy should have been contacted to verify and adjust the medication. The Director of Nursing also confirmed that the medication order should have been verified and followed up with the VA pharmacy, but this was not done. The facility's Medication Pass Policy emphasizes verifying the drug against the electronic medication administration record, which was not adhered to in this case.
Failure to Provide Smooth Consistency Pureed Diets
Penalty
Summary
The facility failed to ensure that a pureed diet was served with a smooth consistency for five residents who required such diets. On July 29, 2024, it was observed that the dietary staff member, V5, pureed salisbury steak patties with beef broth and added thickener powder before placing them in the oven to keep warm. The pureed vegetables were reportedly already prepared. However, during a test tray sampling, the pureed vegetables were found to contain small chunks and casings, and the pureed salisbury steak had chunks that required chewing, indicating that neither was smooth in consistency. The Dietary Manager, V4, confirmed that the pureed vegetables were stringy and inappropriate, and noted that the salisbury steak appeared gritty. V4 acknowledged that pureed food should have a baby food consistency, as outlined in the facility's Puree Basics Fact Sheet, which states that pureed diets are for residents who cannot chew or swallow without difficulty and should be blended to a mashed potato or applesauce consistency.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving two residents. On the night in question, one resident accused her roommate of stealing her phone and account information, despite not owning a phone. This accusation led to the resident using profane and derogatory language towards her roommate, calling her a 'B***' multiple times. The situation escalated to the point where the accused resident felt intimidated and upset by the verbal assault. A Certified Nursing Assistant (CNA) witnessed the incident and reported it to the facility's administrator, as per protocol. The CNA confirmed that the resident's behavior was unusually aggressive and frightening. The administrator instructed the staff to move the aggressive resident to another room for the remainder of the night. The facility's policy on abuse prevention and prohibition clearly states that residents must not be subjected to abuse, including verbal abuse, by anyone. However, in this instance, the facility did not prevent the verbal abuse from occurring.
Failure to Investigate and Report Verbal Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse policy by not identifying, investigating, or reporting an incident of verbal abuse involving two residents. On July 30, 2024, a resident (R16) reported that her roommate (R18) accused her of stealing a phone and used profane language towards her, which was witnessed by a Certified Nursing Assistant (CNA). The CNA reported the incident to the facility's administrator, who instructed the staff to move R18 to another room but did not consider the situation as abuse, attributing it to dementia-like behavior. Consequently, no investigation or report was made regarding the incident. The facility's Abuse, Prevention, and Prohibition Policy clearly defines verbal abuse and outlines the necessary steps for handling such incidents, including identification, investigation, and reporting. Despite this, the administrator did not follow these procedures, as she did not perceive the incident as abuse. The policy emphasizes that residents must not be subjected to abuse by anyone, and the failure to investigate or report the incident represents a breach of this policy. The incident involved R18 using derogatory language towards R16, which was intimidating and upsetting for R16, yet the facility did not take the required steps to address the situation according to their policy.
Failure to Obtain Treatment Orders for Resident's Wounds
Penalty
Summary
The facility failed to obtain treatment orders for non-pressure wounds for a resident, identified as R15, which was observed during a survey. On multiple occasions, R15 was found with untreated wounds on his right arm and right leg. Initially, R15 was seen with a protective sleeve on his right arm, which had dried blood, and a bandaid on his right leg. R15 reported that the bandaid and the dressing on his arm had not been checked or changed for several days. Upon further observation, the dressing on R15's arm was found to have a pool of blood trapped under it, and the bandaid on his leg showed yellow drainage, indicating a lack of proper wound care and monitoring. The Director of Nursing (V2) confirmed that there were no current treatment orders for R15's wounds and acknowledged that the facility's policy required notifying the doctor and obtaining treatment orders when a wound is identified. Despite progress notes indicating the presence of wounds on R15's shin and arm, no treatment orders were documented prior to the survey. The facility's Wound Assessment Policy did not address treatment, and V2 admitted that the facility lacked any wound treatment policies, contributing to the deficiency in care for R15's wounds.
Failure to Change Pressure Ulcer Dressings as Ordered
Penalty
Summary
The facility failed to ensure pressure ulcer prevention treatments were completed as ordered for a resident reviewed for pressure injuries. On July 30, 2024, the resident was observed in a wheelchair with dressings on the right buttock, left buttock, and coccyx that were dated July 28, 2024, indicating they had not been changed as per the physician's orders. The resident reported that a nurse had intended to change the dressings the previous night but did not return to do so. The physician's orders from June 28, 2024, specified that the dressings should be changed daily and as needed during the day shift. The facility's Director of Nursing confirmed that the dressings should have been changed according to the orders. The facility's Weekly Pressure Ulcer Report indicated the resident had a stage 2 pressure ulcer on the coccyx, a stage 3 pressure ulcer on the right buttock, and a stage 2 pressure ulcer on the left buttock.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident's medications were not expired prior to administration, affecting one of the thirteen residents reviewed for medication administration. The resident had a physician's order for Morphine Sulfate oral solution, which was ordered on August 27, 2023. On July 29, 2024, it was observed that the Morphine Sulfate bottle had an expiration date of May 25, 2024, with 5 ml remaining. A registered nurse confirmed the amount of medication and acknowledged that medications should not be used after their expiration date. The Director of Nursing stated that both the nurse and pharmacy should check for expired medications, and they should not be administered past their expiration date. The resident's Controlled Substance Record sheets indicated that 39 doses of Morphine Sulfate were administered after the expiration date, from May 30, 2024, through July 28, 2024. The facility's Medication Storage Policy stated that Morphine Sulfate Oral Solutions should be discarded after the manufacturer's expiration date unless otherwise indicated.
Failure to Ensure Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) psychotropic medication had a stop date, as required by regulations. Specifically, a resident had a physician's order dated July 2, 2024, for clonazepam 0.25 mg to be administered every 8 hours as needed for restlessness/agitation, but the order lacked a stop date. A pharmacy consultation report dated July 18, 2024, noted that the PRN order for the anxiolytic had been in place for more than 14 days without a stop date. According to CMS requirements, PRN orders for non-antipsychotic psychotropic drugs must be limited to 14 days unless the prescriber documents the specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. The Director of Nursing stated that she had faxed the pharmacy recommendations to the doctor but was unsure if a response had been received. The facility's policy on psychotropic medication use, dated September 2022, aligns with the CMS requirement, indicating that PRN psychotropic medications should be limited to 14 days unless extended by the attending physician or prescribing practitioner.
Failure to Secure Controlled Medications with Two-Lock System
Penalty
Summary
The facility failed to ensure that controlled medications were secured by a two-lock system, as required. During an observation, the medication room door was found open, leading into the dining room area, with no nurse present in either location. Inside the medication room, the refrigerator containing controlled substances, including a resident's Morphine Sulfate Oral Solution, was unlocked. The resident had a physician's order for Morphine Sulfate oral solution to be administered as needed for pain or shortness of breath. The Director of Nursing later moved the medication cart into the room and closed the door. A Registered Nurse confirmed that both the medication room door and the refrigerator should have been locked, especially since narcotics were stored there. The Director of Nursing acknowledged that narcotics require two locks to ensure security.
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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.
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Nursing homes near Polo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Pinecrest | 8.1 mi | ★★★★★ | 10 | 0 |
| Heritage Square | 10.1 mi | ★★★★★ | 9 | 0 |
| Dixon Rehab & Hcc | 11.6 mi | ★★★★★ | 0 | 0 |
| Oregon Living And Rehabilitation Center | 11.8 mi | ★★★★★ | 28 | 0 |
| La Bella Of Sterling | 12.6 mi | ★★★★★ | 2 | 0 |
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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.