Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors At Oregon during CMS and state inspections, most recent first.
Failure to Monitor Oxygen Therapy and Maintain Continuous Respiratory Support: A resident with COPD, respiratory failure, and cognitive impairment was moved out of her room for maintenance work and placed in the dining room on an oxygen tank without a phone or close monitoring. The tank ran empty, the resident became lethargic and hypoxic, staff could not stabilize her respiratory status, and she was transferred to the hospital and admitted to the ICU with acute on chronic respiratory failure and acute COPD exacerbation.
Failure to Provide Facial Hair Grooming: A dependent resident with CVA, hemiplegia, cognitive impairment, and ADL dependence was observed with heavy facial hair growth on the chin. The resident stated she preferred not to have facial hair and had not been offered facial hair removal during morning ADLs. Staff verified the facial hair growth, and there was no documentation that grooming or facial hair removal was provided.
A resident with severe cognitive impairment, ESRD on dialysis, DM2, CHF, COPD, malnutrition, and multiple lower-extremity wounds did not receive ordered wound care and off-loading interventions. Staff observed the resident with both heels resting on the mattress without pressure-relief boots or heel elevation, and the left shin skin tear was found open to air without the ordered dressing. CNAs and an LPN confirmed the boots and wound care were not in place as ordered.
A resident with a g-tube, severe cognitive impairment, dysphagia, and other diagnoses had tube placement not verified before meds and flushes. An LPN and RNs attempted to administer meds, flush, and unclog the tube without checking placement first, and the site had dark dried blood and drainage with no dressing in place despite orders and facility policy requiring placement verification and site care.
A resident with acute respiratory failure, depression, anxiety, and insomnia had an MRR in which the pharmacist recommended stopping multiple meds, changing diltiazem IR to ER, and addressing duplicate antidepressant therapy due to fall risk and possible duplicative use. The provider disagreed with the recommendations, but the record did not include any clinical rationale for that disagreement, and the Administrator confirmed none was provided.
Medications on a hall med cart were found open, unlabeled, and undated, including insulin glargine for two residents and Toujeo SoloStar for another resident. An opened vial of insulin glargine was also found without a label or date. The DON confirmed the findings, and the residents involved had diagnoses including DM2 and other chronic conditions.
Failure to implement EBP during direct care for two residents with wounds and indwelling devices. One resident had multiple lower-extremity ulcers and received incontinence care and a mechanical lift transfer with only gloves used, while no gown, PPE, or EBP sign was present. Another resident with a trach and G-tube had orders and a care plan for EBP, but an LPN and RN provided care without gown or gloves, and no sign or PPE was available outside the room.
A resident with multiple medical conditions and intact cognition, who required extensive assistance for ADLs and transfers, requested help from a CNA to clear personal items from the bed so that an RN could perform ordered dressing changes. The CNA did not assist the resident, reported to the RN that the resident had made a mess and should clean it up, and the dressing changes were not completed. The RN viewed the CNA’s conduct and statement as inappropriate and reported the incident by text to the ADON, who did not consider it verbal abuse and did not promptly notify the DON or the state agency or initiate an investigation, contrary to the facility’s abuse reporting policy requiring immediate reporting of alleged violations.
A resident with multiple medical conditions and dependence on staff for ADLs was not assisted into bed for ordered dressing changes after a CNA allegedly refused to help clean off the bed and made an inappropriate comment about the resident cleaning the bed herself. An RN reported this allegation of verbal abuse and refusal of care to the ADON by text, but the ADON did not consider it verbal abuse, did not notify the DON, and did not initiate an investigation as required by facility policy. The resident’s dressing change was not completed as ordered, and there was no documentation of the alleged incident in the medical record during the period reviewed.
Two residents with diabetes received insulin via pen-injectors from an LPN who did not prime the pens before administration, contrary to manufacturer instructions and facility policy. For one resident, the LPN attached the needle, dialed the ordered dose of long-acting insulin, and injected it without priming. For another resident, the LPN similarly dialed the ordered dose of rapid-acting insulin and administered it without priming. The LPN later confirmed believing priming was unnecessary, despite manufacturer directions requiring priming before each injection to remove air and ensure accurate dosing. These observations contributed to a medication error rate above 5%.
Surveyors found that an LPN failed to prime insulin pens before administering ordered doses of Degludec and Lispro to two residents with diabetes and other comorbidities. For each resident, the LPN attached the needle, dialed the full ordered dose, and injected the insulin without first expelling air or confirming a drop of insulin, despite manufacturer instructions and facility policy requiring priming before each injection to ensure accurate dosing.
An LPN failed to follow infection control standards and facility policy by touching oral medications with bare hands and administering them after they had contacted contaminated surfaces. For one resident with multiple chronic conditions and moderately impaired cognition, the LPN dropped two tablets onto the medication cart, picked them up with a bare hand, then handled the cart and computer before giving the pills to the resident, who swallowed them with water. For another resident with complex medical issues, the LPN dropped a Flomax tablet onto the cart and between items on the cart, retrieved it with a bare hand, and also punched multiple other medications from cards into a bare hand before placing them into a medication cup and administering them. The LPN later confirmed this was his usual practice, despite facility policy directing staff not to touch medications with bare hands when removing them from their source.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
An unattended and unlocked medication cart was found near two halls, with a cup containing two used oral syringes that had been used to administer morphine sulphate. An LPN confirmed the cart was left unsecured and the syringes were not properly disposed of, stating they were left by the previous shift. This incident had the potential to affect several cognitively impaired, independently mobile residents in the area.
Surveyors found expired milk and juice, as well as multiple unlabeled and undated food items in kitchen and pantry areas. Food brought in by families or visitors was not consistently labeled or discarded according to policy, and food debris was observed on the floor. Staff confirmed these findings and acknowledged inconsistent cleaning and maintenance practices.
A resident with a diabetic foot ulcer did not have wound measurements completed for over a month, despite having physician orders and a care plan for wound care. Review of records and staff interview confirmed the absence of documented wound measurements, which was not in accordance with the facility's wound management policy requiring ongoing assessment.
The facility failed to ensure proper IV catheter care for three residents, leading to deficiencies in treatment. A resident with multiple medical conditions had a midline catheter without timely dressing changes. Another resident's catheter remained in place beyond the ordered duration, with inadequate dressing maintenance. A third resident's central line dressing was not changed as scheduled. These issues were confirmed through staff interviews and record reviews, indicating non-compliance with physician orders and facility policies.
The facility failed to provide adequate pressure ulcer care, resulting in harm to three residents. One resident developed an unstageable ulcer due to inconsistent care plan implementation, another developed a stage III ulcer without timely intervention, and a third was admitted with untreated wounds, leading to hospitalization. The facility's lack of timely assessment and treatment contributed to these outcomes.
The facility failed to provide adequate personal hygiene care for residents requiring assistance with activities of daily living. Several residents were observed with unclean nails, unwashed hair, and unshaven faces, despite being scheduled for regular showers and personal care. Staff interviews revealed neglect due to fear of resident behaviors and missed scheduled care, violating facility policies on maintaining proper hygiene.
A resident with Alzheimer's and severe cognitive impairment had significant dental issues, including decayed and missing teeth, which were not addressed in her care plan. Despite the resident's refusal of dental interventions and expressed difficulty eating, the facility did not update the care plan to include supports for her dental needs, contrary to their policy requiring comprehensive care plans.
A resident with severe cognitive impairment and multiple medical conditions was not provided with alternative communication methods as indicated in their care plan. Despite recommendations for a communication sheet, staff were unaware and untrained in its use, leaving the resident to rely on gestures and nods for communication.
The facility failed to implement ordered interventions for two residents to promote range of motion and limit contractures. One resident was observed without the prescribed lap tray for safe arm positioning, and another was without rolled washcloths in their hands, despite orders. Staff interviews confirmed the absence of these interventions, indicating non-compliance with care plans.
The facility failed to enforce its smoking policy, allowing two residents to retain smoking materials and smoke in non-designated areas. One resident was found with cigarettes and observed smoking in a prohibited area, while another had burn marks on his clothing from unsafe smoking practices. Despite the facility's policy, these residents were initially allowed to keep their cigarettes, leading to potential safety hazards.
The facility failed to involve a cognitively intact resident in care planning and did not update another resident's care plan to reflect a change in smoking status. One resident expressed a desire to participate in care planning but had not been included since readmission. Another resident, who was a smoker, had his cigarettes removed due to safety concerns, but his care plan lacked updates to address unsafe smoking. The DON confirmed the absence of a smoking care plan.
A resident with multiple health conditions, including diabetes and chronic respiratory failure, was found to have undetected skin integrity issues, including a diabetic foot ulcer, despite having a care plan and orders for regular skin assessments. The facility failed to identify and report these issues in a timely manner, leading to a deficiency.
A resident with conductive hearing loss and impacted earwax did not receive timely audiology services despite being highly hearing impaired and lacking hearing aids. The resident, who was cognitively intact, communicated through written questions and expressed the need for ear cleaning and audiology services. The facility delayed contacting audiology for approximately three months after the resident's admission, leading to a deficiency investigation.
A resident, who was continent and required assistance for toileting due to left side weakness, experienced an episode of incontinence after the night staff failed to respond to his call light. Despite being cognitively intact and dependent on staff for toileting, the resident was left unattended, resulting in soiling himself. This incident highlights a failure to adhere to facility policies on maintaining residents' toileting abilities.
A resident with multiple health issues, including hemiplegia and depression, did not receive adequate grooming and hygiene care in an LTC facility. The resident, dependent on staff for ADLs, had only three documented showers over a month and had untrimmed fingernails with a black/brown substance. Staff interviews confirmed the lack of grooming and missed showers, and the DON acknowledged the failure to adhere to the resident's care schedule.
A resident with multiple medical conditions and frequent bowel incontinence was not provided timely care, resulting in the resident being found with dried stool upon hospital admission. Despite a care plan requiring regular checks, staff failed to perform necessary incontinence monitoring.
Failure to Monitor Oxygen Therapy and Maintain Continuous Respiratory Support
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who was ordered supplemental oxygen to keep oxygen saturation above 88%. Resident #59 had a history of acute respiratory failure, COPD, acute on chronic diastolic heart failure, moderate cognitive impairment, and used a manual wheelchair with staff assistance for mobility. The resident also used oxygen therapy and a non-invasive mechanical ventilator, and the care plan directed staff to observe for signs and symptoms of respiratory distress and hypoxia and to administer oxygen as ordered. On 12/09/25, maintenance staff needed to work in the resident’s room, so the resident was removed from the room and taken to the dining room on an oxygen tank. The resident stated she was taken without her telephone and had no way to call for help. The resident reported that while in the dining room, the oxygen tank ran out and she was unable to alert staff. The maintenance director confirmed the work took approximately three hours, and the CNA stated she took the resident to the dining room around 9:00 A.M. and later noticed around 1:00 P.M. that the resident was less responsive and the oxygen tank was empty. When respiratory therapy was called, the resident was found in a wheelchair with an oxygen saturation of 65%, a heart rate of 101, and lethargy. Staff attempted to stabilize the resident with AVAPS, increased oxygen, and then a non-rebreather mask, but the resident remained difficult to maintain at an acceptable oxygen level and EMS was called. The resident was sent to the hospital, where she was found to be hypoxic with respiratory acidosis and was admitted to the ICU with acute on chronic respiratory failure and acute COPD exacerbation. The DON stated the facility was not monitoring the resident’s oxygen saturation daily to ensure it remained above 88% as ordered, and the CNP confirmed the resident should not have been left alone when connected to an oxygen tank.
Failure to Provide Facial Hair Grooming
Penalty
Summary
The facility failed to ensure a dependent resident was provided adequate facial hair grooming. Resident #25 was admitted with diagnoses including cerebral infarction with left-sided hemiplegia, hypertension, anxiety disorder, chronic pain syndrome, panic disorder, and depression. The most current MDS showed moderate cognitive impairment, no recorded behaviors, upper and lower extremity range of motion impairment on both sides, dependence on staff for ADLs, bowel and bladder incontinence, and risk for pressure ulcer development. The care plan addressed ADL self-care deficits and included assistance with bathing, bed mobility, dressing, and personal hygiene. A physician order required bathing every Tuesday and Friday with documentation of refusals or requests for a different day or time, and shower documentation showed baths were provided on multiple dates with no refusals documented. Despite this, there was no documentation that Resident #25 received facial hair grooming or removal. During observation, the resident was seated in a wheelchair in the dining room and had heavy hair growth covering her chin. The resident stated she preferred not to have facial hair and had not been offered facial hair removal during morning ADLs. On a later observation, the resident remained in bed with heavy facial growth to her chin. CNA #284 and CNA #233 verified the facial hair growth, and CNA #284 found the resident's personal razor in her bathroom. The facility's ADL policy stated that residents unable to perform ADLs would receive necessary services to maintain grooming and personal hygiene.
Failure to Implement Ordered Wound Treatments and Heel Off-Loading
Penalty
Summary
The facility failed to ensure wound treatments and interventions were implemented as prescribed for Resident #33, who was admitted with multiple diagnoses including cerebral infarction, metabolic encephalopathy, anemia, end stage renal disease with dialysis dependence, type II diabetes mellitus with long term insulin use, COPD, Crohn's disease, CHF, protein calorie malnutrition, CAD, osteoarthritis of the left hip, and muscle weakness. The resident's most current MDS assessed severe cognitive impairment, dependence for many activities of daily living, incontinence of bowel and bladder, and risk for pressure ulcer development, with a stage 3 pressure ulcer present on admission. A nursing plan of care addressed impaired skin integrity related to venous wounds of the left ankle and left heel and a skin tear to the left shin, with interventions including treatment per orders, turning and repositioning, wound evaluations, heel elevation, a pressure redistribution mattress, and wound consultation as needed. A wound specialist evaluation identified a left shin skin tear measuring 4.7 cm by 1.7 cm by 0.1 cm with moderate serosanguinous drainage, an arterial wound to the left anterior ankle measuring 5.3 cm by 5.1 cm with no measurable depth due to dried fibrinous exudate, and an arterial wound to the left heel measuring 3.3 cm by 5.3 cm with no measurable depth due to dried fibrinous exudate. Physician recommendations included off-loading the wounds and floating the heels in bed. Orders were entered for a left shin skin tear treatment with cleansing, Xeroform, and border gauze every other night shift, and for off-loading boots to both feet to be worn at all times as tolerated. Despite the orders, observations showed the resident in bed with both heels resting directly on the mattress and no pressure relief boots or heel elevation in place on multiple occasions. The resident stated he had pressure relief boots when admitted but did not know where they went and had not had them for an undisclosed amount of time, and said he would wear them if staff applied them. The left shin skin tear was also observed open to air with no dressing applied. CNA staff verified the resident had no heel elevation or pressure relief boots in place during care, and an LPN verified the resident was to have pressure relief boots due to heel wounds. Another CNA later stated she was unaware the resident was supposed to have pressure relief boots or lower extremity elevation due to the wounds. The wound treatment management policy stated wound treatments would be provided in accordance with physician orders, including cleansing method, dressing type, and frequency of dressing change.
G-tube Placement Not Verified Before Medications and Flushes
Penalty
Summary
G-tube care was incomplete for a resident with cerebral infarction, dysphagia, tracheostomy, epilepsy, severe cognitive impairment, and dependence on staff for care. The resident had physician orders to cleanse the gastrostomy tube site with soap and water daily and as needed, apply a drain sponge as needed, and check tube placement prior to administering medications and tube feeding/flushes. During observation, an LPN attempted to give morning medications through the g-tube without checking placement first, then forcefully pushed the syringe plunger when the medication would not flow, poured the medication back into the cup, and attempted to milk the tube and flush it without success. Subsequent observations showed an RN also attempted to flush the g-tube without checking placement first and tried to unclog it with a declogger. Another RN later attempted to milk the tube, noted dark dried blood and drainage around the site with no dressing in place, and then forcefully pushed air and water into the tube. Interviews confirmed placement was not checked before the attempts to administer medications and flush the tube, and one nurse stated she only knew to check residual for placement. The facility policy required licensed nurses to verify tube placement before feeding and before administering medications, and to cleanse and dress the site when needed.
Missing Clinical Rationale for Pharmacist MRR Disagreement
Penalty
Summary
The facility failed to provide clinical rationale to support a provider’s disagreement with a pharmacist’s medication regimen review for one resident. Resident #6 was admitted on 05/20/26 with diagnoses including acute respiratory failure, depression, anxiety, and insomnia. In the resident’s MRR dated 05/26/26, the pharmacist recommended discontinuing oxycodone, trazodone, hydroxyzine, fluoxetine, midodrine, lisinopril, doxazosin, diltiazem, atorvastatin, insulin glargine, and Humalog because of the resident’s high and moderate fall risk. The same MRR also recommended discontinuing diltiazem IR 60 mg and changing it to diltiazem 60 mg ER. The pharmacist further noted that the resident had orders for two antidepressants, fluoxetine and trazodone, and stated that use of more than one antidepressant may be viewed as duplicative therapy and may increase the risk of unwanted serotonergic effects. The provider disagreed with the pharmacist’s recommendations, but the medical record did not include clinical rationale for that disagreement. The Administrator confirmed during interview that no clinical rationale had been provided for the provider’s disagreement with the pharmacist’s recommendations.
Unlabeled and Undated Insulin on Medication Cart
Penalty
Summary
Medications were not properly labeled and dated on the [NAME] hall medication cart. During observation on 06/24/26 at 8:45 A.M., Resident #7's insulin glargine, Resident #19's insulin glargine, and Resident #3's Toujeo SoloStar were all open and not dated. The cart also contained an opened vial of insulin glargine 100 u/mL that was not labeled or dated. The Director of Nursing confirmed these findings during interview at 8:50 A.M. The affected residents had diagnoses including type II diabetes mellitus, with Resident #7 also having end stage renal disease and anxiety disorder, Resident #19 having hyperlipidemia and major depressive disorder, and Resident #3 having heart failure and atrial fibrillation. Physician orders showed Resident #7 was ordered insulin glargine 15 units SQ in the morning, Resident #19 was ordered insulin glargine 36 units SQ in the morning, and Resident #3 was ordered Toujeo SoloStar 68 units SQ in the morning. Manufacturer instructions for insulin glargine stated vials in use should be discarded after 28 days, and the facility policy required medications to be stored according to manufacturer recommendations.
Failure to Implement Enhanced Barrier Precautions During Direct Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented for residents with wounds and indwelling medical devices during direct care. Resident #66 had severe cognitive impairment, was dependent on staff for activities of daily living, was incontinent of bowel and bladder, and had multiple arterial/venous ulcers requiring dressing treatments to the right heel, left foot first toe, left lateral malleolus, left lateral foot, and left heel. The medical record showed no physician order or plan of care for EBP for this resident. During observation, two CNAs provided incontinence care and transferred Resident #66 from bed to a reclining geriatric chair using a mechanical lift while wearing disposable gloves only. No gown was used, and no PPE or EBP sign was observed in the room or nearby. The CNAs later confirmed they did not implement EBP while providing direct care and stated no gowns or additional PPE were accessible on the unit. Resident #73 had diagnoses including cerebral infarction, dysphagia, tracheostomy, and epilepsy, and the admission MDS showed severe cognitive impairment and dependence on staff care. The care plan and physician orders required EBP related to the tracheostomy and gastrostomy tube, including use of gown and gloves during direct care. However, observations showed no EBP sign or PPE outside the room, and an LPN and an RN provided medication-related care without gowns or gloves. The RN manager and both nurses confirmed PPE was not worn and that the room lacked the required sign and PPE availability.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state agency as required by policy. A resident with intact cognition, admitted with diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, was care planned to require assistance of two staff for bed mobility and mechanical lift transfers. On the date in question, an RN requested that a CNA transfer the resident to bed so wound dressings could be changed. Later, the CNA reported to the RN that the resident refused to get into bed and that the resident had asked for help to clean off her bed so she could be transferred. The CNA also reported telling the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident with cleaning the bed or transferring her, resulting in the ordered dressing changes not being completed that day. The RN considered the CNA’s statement and failure to assist as inappropriate and reported this information by text message to the ADON that evening. The ADON received the RN’s text describing the CNA’s refusal to help and the statement made to the resident but did not consider it verbal abuse and took no further action at that time. The ADON did not report the allegation to the DON and did not initiate an investigation until two days later, at which time the DON was informed. Interviews confirmed that the resident did not recall the specific alleged statement but did recall that the CNA said she would return after answering another call light and did not come back, and that the dressing change was not completed as ordered. The facility’s abuse, neglect, and exploitation policy required that alleged violations be reported immediately, but not later than two hours if involving abuse or serious bodily injury, and not later than 24 hours otherwise, to the Administrator, state agency, adult protective services, and other required agencies. The failure of the ADON to promptly report the allegation and initiate an investigation, and the lack of timely reporting to the state agency, constituted non-compliance with the facility’s abuse reporting policy.
Failure to Investigate Alleged Verbal Abuse and Missed Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse toward a resident and related failure to provide ordered care. The resident had diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, with intact cognition and dependence on staff for toilet hygiene, personal hygiene, and transfers requiring two-person assistance and a mechanical lift. On the date in question, an RN asked a CNA to transfer the resident to bed for dressing changes. The RN later reported that the CNA told her the resident refused to get into bed and that the CNA stated she told the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident in cleaning off the bed or transferring to bed. As a result, the resident’s dressing changes were not completed as ordered that day. The RN texted this information to the ADON that evening, reporting the CNA’s alleged statement and refusal to help. The ADON acknowledged receiving the text, stated she did not feel the statement was verbal abuse, and took no further action at that time, including not reporting the concern to the DON and not initiating an investigation. The facility’s abuse policy required an immediate investigation when there is suspicion or a report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons and documenting the investigation. The DON later confirmed that the allegation of verbal abuse should have been promptly reported and investigated. Review of the resident’s record showed no progress notes regarding the alleged verbal abuse during the relevant period, and the resident confirmed her dressing was not changed as ordered on the date in question.
Failure to Prime Insulin Pens Resulting in Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with surveyors identifying 2 errors out of 36 observed opportunities, resulting in a 5.5% error rate. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed that medications and insulin be administered as ordered. The physician’s order specified a morning subcutaneous dose of 15 units of insulin Degludec via pen-injector. During continuous observation, an LPN prepared the Degludec insulin pen by attaching the needle, dialing the pen to 15 units, and administering the insulin subcutaneously without priming the pen beforehand. A second resident, with diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, also had a care plan directing administration of medications and insulin as ordered. The physician’s order required 4 units of insulin Lispro via pen-injector to be given subcutaneously before meals and at bedtime. Observation showed the same LPN dialed the Lispro pen to 4 units and administered the insulin without priming the pen. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both the Degludec and Lispro pen-injectors, as well as facility policy, required medications to be administered in accordance with manufacturer specifications, including priming the pens before each injection to remove air and ensure correct dosing.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure insulin pens were primed prior to insulin administration, contrary to manufacturer instructions and facility policy, resulting in significant medication errors for two residents. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed staff to administer insulin per physician orders. The physician ordered Degludec insulin via pen-injector, 15 units subcutaneously in the morning. During continuous observation of a medication pass, an LPN attached a needle to the Degludec pen, dialed the pen directly to 15 units, entered the resident’s room, and administered the insulin subcutaneously without priming the pen. The second affected resident had diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, and also had a care plan intervention to administer insulin per physician orders. The physician ordered Lispro insulin via pen-injector, 4 units subcutaneously before meals and at bedtime. During observed medication administration, the same LPN dialed the Lispro pen directly to 4 units and administered the insulin without priming. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both Degludec and Lispro pens, as well as facility policy, required priming the pen (dialing 2 units, expelling air until a drop of insulin appears) before each injection to remove air and ensure correct dosing, and noted that not priming may result in too much or too little insulin being delivered.
Improper Handling of Oral Medications During Preparation and Administration
Penalty
Summary
The deficiency involves failure to maintain infection control standards during medication preparation and administration. For one resident with traumatic brain injury, type II diabetes, muscle weakness, depression, dysphagia, and moderately impaired cognition, an LPN prepared morning medications including Celexa and Vimpat. During preparation, the LPN dropped the Celexa tablet onto the top of the medication cart, where it bounced multiple times, then picked it up with a bare hand and placed it into the medication cup. The same process occurred with the Vimpat tablet, which was also dropped on the cart and then picked up with a bare hand and placed into the cup. After preparing all medications, the LPN handled the medication cart drawers and computer mouse, then picked up the medication cup and handed it to the resident, who ingested the pills with water. For a second resident with acute and chronic respiratory failure with hypoxia, type II diabetes, peripheral vascular disease, chronic kidney disease, hypertension, and moderately impaired cognition, the same LPN prepared multiple morning medications including Flomax, buspar, carvedilol, clopidogrel, ferrous sulfate, folic acid, lasix, levothyroxine, protonix, potassium chloride, and seroquel. The LPN dropped the Flomax tablet on the top of the medication cart, where it bounced and landed between the narcotic book and a tray holding water and medication supplies, then picked it up with a bare hand and placed it into the medication cup. The LPN then repeatedly punched each of the remaining medications from their cards into one bare hand before transferring them into the medication cup. After returning the punch cards to the cart drawer and using the computer mouse, the LPN carried the medication cup to the resident’s room and observed the resident take all pills with water. In an interview, the LPN confirmed touching the pills with bare hands, including the dropped Flomax, and stated that he usually punches residents’ pills into his bare hands because he drops them when attempting to punch them directly into the cup. Facility policy on medication administration stated that staff should take care not to touch medications with a bare hand when removing them from the source.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unattended and Unlocked Medication Cart with Improper Disposal of Oral Syringes
Penalty
Summary
Surveyors observed an unattended and unlocked medication cart near the C and D Halls of the facility during early morning hours. On top of the cart, there was a clear plastic drinking cup containing two small oral syringes, which had been used to administer morphine sulphate. Small droplets of an unknown clear substance were present on the syringes and inside the cup. No staff were present in the area at the time of observation. Shortly after, an LPN exited a resident's room at the far end of the D Hall and confirmed that the medication cart was left unlocked and unattended. The LPN stated that the syringes were left by the night shift and that she was attempting to clean up the mess, noting that shift change had occurred approximately one hour prior. The facility's policy on medication storage, revised in January 2024, requires that all medications be stored securely and that medication carts remain locked or under direct observation during medication passes. The failure to secure the medication cart and properly dispose of used oral syringes was found to have the potential to affect seven residents identified as cognitively impaired and independently mobile, all residing on the C and D Halls. This deficiency was identified during a complaint investigation.
Expired and Unlabeled Food Items Found in Facility Storage
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard food items in accordance with professional standards and facility policy. During a kitchen inspection, expired food items were found, including 38 cartons of one percent milk past the expiration date, two unopened thickened orange juice containers with an expiration date several months prior, and an unopened thickened apple juice with an expiration date in the future. The Dietary Manager confirmed the presence of these expired items. In the east pantry, food brought in by residents or visitors was found unlabeled or past the date, including a fast-food bag and a container of potato salad, as well as food debris on the floor. The Licensed Practical Nurse verified these findings and stated that dietary staff maintained temperature logs and cleaned the refrigerator two to three times per month, but all staff were responsible for its maintenance. Further inspection of the west pantry revealed additional issues, such as unlabeled and undated grocery bags of unknown food, undated restaurant boxes, and an expired carton of milk. The Medical Records Clerk confirmed these findings. Review of facility policies showed that all foods should be labeled, dated, and stored according to safe food handling practices, and food brought in by families or visitors must be labeled, dated, and consumed within three days or discarded. The facility failed to follow these policies, resulting in improper storage and retention of expired and unlabeled food items, potentially affecting all residents except those identified as receiving no food by mouth.
Failure to Complete Wound Measurements for Ongoing Assessment
Penalty
Summary
The facility failed to ensure that wound measurements were completed for ongoing assessment of a resident's diabetic foot ulcer. Medical record review showed that the resident, who had multiple diagnoses including diabetes mellitus, end stage renal disease, and dependence on renal dialysis, was admitted with a diabetic foot ulcer and had a physician's order for daily wound care. The care plan included interventions to complete wound treatment as prescribed. However, review of the skin and wound assessments from mid-June through late July revealed that no measurements of the diabetic wound were documented during this period. An interview with a registered nurse confirmed that the resident's wound was not measured between the specified dates. The facility's policy on wound treatment management required ongoing assessment of wounds, including monitoring the effectiveness of treatments. The lack of wound measurements was not in accordance with the facility's policy and current wound standards of practice, as ongoing assessment is necessary to monitor healing and determine if modifications to treatment are needed.
Deficiencies in IV Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and maintenance of intravenous (IV) catheters for three residents, leading to deficiencies in their treatment. Resident #1, who had multiple complex medical conditions including respiratory failure and diabetes, had a midline catheter inserted with a physician's order for dressing changes every seven days. However, documentation showed that the dressing was not changed after a certain date, and the Assistant Director of Nursing confirmed the lack of documentation for the required dressing changes. Resident #2, who was dependent on a ventilator and had chronic respiratory failure, had a midline catheter placed for a one-day antibiotic therapy. Despite the order to remove the catheter after one day, the catheter remained in place with no current orders for its care. An observation revealed the dressing was peeling and there was dried blood at the insertion site, indicating a lack of proper maintenance and documentation. Resident #3, who was in a persistent vegetative state and had a central line, also experienced a lapse in care. The central line dressing was not changed as per the seven-day schedule, and the facility's policy required documentation of catheter care, which was not adequately maintained. These findings were confirmed through staff interviews and medical record reviews, highlighting the facility's failure to adhere to physician orders and its own policies for IV catheter care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention, resulting in actual harm to three residents. Resident #79 was admitted with multiple health conditions, including cerebral infarction and diabetes, and was at risk for impaired skin integrity. Despite having a care plan that included interventions such as the use of an air mattress and regular repositioning, the facility did not consistently document or implement these measures. Resident #79 developed an unstageable pressure ulcer, which was not identified or treated in a timely manner, leading to the resident's hospitalization. Resident #40, who had a history of chronic respiratory failure and was dependent on staff for daily living activities, developed a stage III pressure ulcer. The facility failed to implement hospital-recommended skin treatments upon the resident's return from a hospital stay. There was a lack of documentation and timely intervention for the resident's skin condition, and the family expressed concerns about the timeliness of care, including repositioning and incontinence care. Resident #184 was admitted with multiple wounds, including unstageable pressure ulcers and a deep tissue injury, but did not receive any treatments for these conditions while at the facility. The facility's records did not reflect the presence of these wounds, and the resident was eventually sent to the hospital with a necrotic area on the coccyx, sepsis, and respiratory failure. The facility's failure to assess and treat the resident's wounds promptly contributed to the resident's deteriorating condition.
Deficiency in Providing Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate and timely care for residents who required assistance with activities of daily living, specifically in maintaining personal hygiene, including nail care, bathing, and shaving. This deficiency affected four residents out of the seven reviewed. The facility's policies on activities of daily living and bathing were not adhered to, resulting in residents not receiving the necessary services to maintain good grooming and hygiene. Resident #16, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed with long, unclean fingernails, oily and uncombed hair, and dried food on his shirt. Staff interviews revealed that many were afraid of the resident due to his behaviors, leading to neglect in providing nail care and showers. Despite being scheduled for showers twice a week, the resident had not been showered in a long time, receiving only daily bed baths instead. Resident #15, with intact cognition and dependent on staff for activities of daily living, reported not having received a shower since May, only a couple of bed baths. The resident's hair was greasy and matted, and the facility's documentation confirmed missed showers on scheduled days. Similarly, Resident #19, who was dependent on staff for mobility and activities of daily living, was observed with unshaven whiskers, despite being scheduled for regular bed baths. Resident #185, who was ventilator-dependent and required assistance with bathing and personal hygiene, also reported not receiving regular showers or shaving assistance, with documentation confirming missed bathing days.
Failure to Address Dental Needs in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the dental needs of a resident, which was identified during a review of medical records, observations, and interviews. The resident, who was admitted with multiple diagnoses including Alzheimer's disease and chronic kidney disease, was found to have significant dental issues, including three decayed teeth, one missing tooth, and six root tips, as noted in a dental appointment. Despite these findings, the resident's care plan did not include supports or interventions for these oral health concerns. The resident, who was severely cognitively impaired, expressed difficulty eating due to her dental condition, which was observed during an interview. The resident had refused dental extractions and other interventions, and the facility was aware of these refusals. However, the care plan was not updated to reflect the resident's dental needs or to provide alternative supports. The facility's policy on comprehensive care plans requires that they include measurable objectives and timeframes to meet all of a resident's needs, but this was not adhered to in this case.
Failure to Provide Alternative Communication Methods
Penalty
Summary
The facility failed to provide alternative methods of communication for a resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction with left side hemiplegia and hemiparesis. The resident was dependent on staff for activities of daily living and had impaired communication due to a cerebral vascular accident. Although the nursing plan of care was revised to address the resident's impaired communication, no formal communication tool or technique was established. Observations noted the resident attempting to communicate through gestures and eye contact, but no communication board or alternate means of communication was available in the room. Interviews with staff, including a Speech Language Pathologist (SLP) and nursing aides, revealed a lack of awareness and training regarding the use of a communication sheet that was previously recommended for the resident. The SLP confirmed that a communication sheet was implemented but did not provide additional staff training. Staff members, including a State Tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN), were unaware of the communication sheet's existence or its intended use. The communication sheet was found on the resident's dresser, unused, while the resident continued to rely on gestures and nods for communication.
Failure to Implement ROM Interventions for Residents
Penalty
Summary
The facility failed to implement ordered interventions to promote range of motion and limit contractures for two residents. Resident #24, who has severe cognitive impairment and is dependent on staff for activities of daily living, was observed without the prescribed left half lap tray for safe arm positioning. Despite physician orders and documentation indicating the tray was applied, observations revealed it was missing, and the resident's left arm was resting in her lap with a closed fist. Staff interviews confirmed the absence of the tray and the presence of jagged plastic edges on the wheelchair armrest. Resident #19, with multiple diagnoses including chronic respiratory failure and contractures, was observed without the ordered rolled washcloths in both hands, which were intended to manage contractures. Despite documentation indicating compliance, observations showed the resident's hands were tightly clenched without washcloths. Staff interviews revealed uncertainty about the absence of the washcloths, and attempts to place them were met with resistance and difficulty, indicating the intervention was not being followed as required. The facility's policy on activities of daily living emphasizes maintaining the highest practicable outcomes for residents, yet the observations and interviews indicate a failure to adhere to prescribed interventions for these residents. This lack of compliance with physician orders and care plans resulted in deficiencies in the care provided to residents #24 and #19, potentially impacting their range of motion and contracture management.
Failure to Enforce Smoking Policy and Secure Smoking Materials
Penalty
Summary
The facility failed to adhere to its policy regarding the secure storage of smoking materials and ensuring residents smoked only in designated areas. This deficiency was observed in two residents, both of whom were cognitively intact and had been assessed for smoking safety. Resident #70 was found with cigarettes in his possession and was observed smoking in a non-designated area, despite the facility's policy prohibiting smoking on the premises. Interviews confirmed that Resident #70 was aware of the smoking rules but continued to keep his smoking materials with him and smoke in unauthorized areas. Resident #13, who also had cigarettes in his possession, was found with burn marks on his clothing, indicating unsafe smoking practices. Despite the facility's policy, Resident #13 was initially allowed to keep his cigarettes, but they were later confiscated after staff observed him falling asleep while smoking and burning holes in his clothes. The Director of Nursing confirmed that Resident #13 was reassessed and deemed unsafe to smoke independently, leading to the removal of his smoking materials. The facility's Smoking/Non-Smoking Policy, which prohibits smoking on any facility property and the retention of smoking materials by residents, was not effectively enforced. This resulted in residents smoking in non-designated areas and retaining smoking materials, posing potential safety hazards. The policy was not consistently applied, as evidenced by the differing treatment of the two residents involved.
Deficiencies in Resident Care Planning and Smoking Status Updates
Penalty
Summary
The facility failed to ensure that residents and/or their representatives participated in care planning, affecting one resident who was cognitively intact and expressed a desire to be involved in his care plan development. Despite being readmitted to the facility, there was no record of a care plan meeting held with the resident, and the resident confirmed he had not participated in any care planning meetings since his return. The facility's administrator verified the absence of care conference information for this resident. Additionally, the facility did not update a resident's care plan to reflect a change in smoking status, affecting another resident who was cognitively intact and had a history of smoking. The resident was observed with burn marks on his clothing and reported that his cigarettes were taken and returned by staff. The resident's cigarettes were removed again after being found falling asleep while smoking, but the care plan had not been updated to address unsafe smoking. The Director of Nursing confirmed the lack of a smoking care plan and stated it would be updated.
Failure to Timely Identify and Assess Skin Integrity Issues
Penalty
Summary
The facility failed to identify, report, and timely assess an alteration in skin integrity for a resident, leading to a deficiency. The resident, who had multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus, and was at risk for skin breakdown, was observed to have two darkened scabbed areas on the left foot during personal care. Despite having a care plan that included interventions for skin integrity, such as frequent repositioning and pressure-relieving devices, the facility did not detect these skin issues in a timely manner. The resident's medical record indicated that weekly skin assessments were ordered, but observations revealed dark crusty areas on the toes that were not previously documented. A podiatry note later confirmed the presence of small eschars on the right foot, and a skin wound evaluation identified a new diabetic foot ulcer on the right great toe. The facility's clinical protocol required prompt intervention for at-risk residents, but the deficiency was noted under complaint investigations, indicating a lapse in adherence to these protocols.
Delayed Audiology Services for Resident with Hearing Concerns
Penalty
Summary
The facility failed to provide timely audiology services for a resident with identified hearing concerns. Resident #70, who was admitted with diagnoses including conductive hearing loss and impacted earwax, was cognitively intact and required assistance with certain activities of daily living. Despite being highly hearing impaired and lacking hearing aids, the resident's care plan included interventions for impaired communication and an audiology referral as needed. However, the resident had not been seen by an audiologist since admission, and no appointment had been scheduled, even though the resident had authorized audiology services. Interviews revealed that the resident was unable to hear and communicated through written questions, expressing the need for ear cleaning and audiology services. The resident reported a history of needing regular earwax removal due to past eardrum repairs, which was not addressed by the facility. The Social Services Director confirmed that the first contact with audiology was made approximately three months after the resident's admission, indicating a significant delay in addressing the resident's hearing needs. This deficiency was investigated under a specific complaint number.
Failure to Assist Continent Resident Leads to Incontinence Episode
Penalty
Summary
The facility failed to provide adequate and timely care to prevent an episode of incontinence for a resident who was continent of bowel and bladder. Resident #69, who was admitted with diagnoses including hemiplegia, hemiparesis, stroke, and benign prostatic hyperplasia, was cognitively intact and dependent on staff for toileting due to left side weakness. Despite being always continent and not on a toileting program, Resident #69 required assistance to use the bathroom, especially at night due to medication effects. An incident occurred when Resident #69 activated the call light during the night shift, needing assistance to use the bathroom. The night staff turned off the call light but did not return to assist, resulting in the resident soiling himself. This was confirmed by a State tested Nursing Assistant (STNA) who found the resident in this condition during the first shift. The facility's policies on Activities of Daily Living and Incontinence, which emphasize maintaining a resident's ability to toilet, were not adhered to, leading to this deficiency.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, was admitted with multiple diagnoses including hypertension, peripheral vascular disease, and depression. The resident required substantial to maximal assistance with transfers, was incontinent, and was at risk for pressure ulcer development. Despite these needs, the facility did not consistently provide scheduled showers or maintain the resident's personal hygiene, as evidenced by long, jagged fingernails with a black/brown substance underneath. Observations and interviews revealed that the resident did not receive showers as scheduled, with only three documented showers over a 30-day period. The resident reported that their fingernails had not been trimmed since admission, and staff interviews confirmed the lack of grooming and missed showers. The Director of Nursing verified the resident's shower schedule and acknowledged the failure to provide the necessary care. This deficiency was investigated under two complaint numbers, indicating a pattern of non-compliance in the facility's care practices.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and sufficient care for a resident who was dependent on staff for activities of daily living and experienced frequent bowel incontinence. The resident, who had multiple medical conditions including atrial fibrillation, congestive heart failure, and diabetes, was assessed to have intact cognition and was at risk for pressure ulcers due to moisture-associated skin damage. Despite a care plan that required regular checks and incontinence care, the resident was found covered in dried stool upon admission to the hospital emergency room. On the day of the incident, a State tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN) were responsible for the resident's care. The STNA did not perform incontinence checks, relying on the resident to call out for assistance, and the LPN did not assess the resident for bowel incontinence during her shift. The Director of Nursing confirmed that the resident required incontinence monitoring every two hours, which was not provided, leading to the deficiency noted in the report.
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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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Illustrative
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Nursing homes near Oregon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Villa | 0.4 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Toledo Snf | 1.3 mi | ★★★★★ | 1 | 0 |
| Ayden Healthcare Of Oregon | 1.5 mi | ★★★★★ | 11 | 0 |
| The Gardens Of St. Francis | 2.8 mi | ★★★★★ | 12 | 0 |
| Majestic Care Of Perrysburg | 5.6 mi | ★★★★★ | 34 | 0 |
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